The American Cancer Society's advocacy arm is out with a new report this morning that reviewed the plans, which the Trump administration has pushed as an alternative to Obamacare.
Cancer is a useful test of the plans' coverage, given the disease's severity and its tendency to surprise patients,
This article analyzes annual cost profiles and consumption patterns of Medicare beneficiaries with diabetes from 2000 to 2006. It finds that while the percentages of beneficiaries and expenditures in different consumption clusters (ranging from "crisis consumers" to "low consumers") remained generally constant year to year, there was significant movement of individuals between clusters over time. Notably, a large proportion of those in the lowest clusters in one year transitioned to the highest clusters in subsequent years, representing a significant portion of inpatient costs. This dynamic migration between clusters, with individuals moving from low to high usage, was a previously unrecognized trend with important implications for targeting of disease management programs.
This document proposes a medical cannabis clinical model program called Veterans for Compassionate Care (VFCC) in Washington State. The program would provide full medical and behavioral health services using cannabis, including growing pharmaceutical-grade cannabis. It aims to reduce opioid use and costs, provide jobs for veterans, and collect clinical data on cannabis therapies. The proposal requests state approval and funding to pilot the closed-loop clinical model program for qualifying patients like veterans with PTSD, chronic pain, and other conditions.
Effective Disease Management (DM) can improve the health of many Americans suffering from chronic illness while reducing costs to patients, health care providers, employers and more. Discover how use of DM from McKesson is helping to improve patient safety and medication safety.
The VA healthcare system is inefficient due to policies that resulted in veterans dying while waiting for appointments. An investigation found VA employees were falsifying appointment times. The VA's goal of seeing patients within 30 days is unacceptable compared to Medicare patients seeing doctors within 3 days. Two alternative policies are proposed to increase efficiency: 1) A hybrid system using Medicare for non-service related care and the VA for service-related care. 2) Removing priority groups 7 and 8 from VA healthcare to reduce wait times by 50% for service-disabled veterans in groups 1-6.
1) The document discusses how health information technology (HIT), such as electronic health records (EHRs) and health information exchanges (HIEs), has the potential to influence health reform efforts in the United States by reducing costs, increasing access to care, and improving quality of care.
2) The Affordable Care Act includes provisions and financial incentives to encourage widespread adoption of EHRs and use of HIT. Meaningful use criteria aim to ensure EHRs improve safety, quality, and coordination of care.
3) HIT such as EHRs and HIEs could transform healthcare by giving providers access to complete patient information, reducing medical errors, duplicative tests, and costs
Health Reform Alert - Implementation Guidance FAQsCBIZ, Inc.
The ACA’s governing agencies (Labor, HHS and IRS) have issued their 18th set of implementation FAQs, further defining certain aspects of the Affordable Care Act, as well as how the law coordinates with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Following are highlights of this guidance.
Learn more at www.cbiz.com
Meaningful Use and the Path to Population Health and Quality in a Transformin...Phytel
The over arching goal of the meaningful use requirements of the 2009 American Recovery and Reinvestment Act (ARRA) is to facilitate the transition to real quality improvement and population health management. Most physician practices will need supplemental information technology that automates the basic tasks of identifying, contacting, and tracking patients who need preventive and chronic care services, coupled with reports that care teams can use for quality improvement and reporting.
Jeffrey Brenner is a primary care physician in Camden, New Jersey who founded the Camden Coalition of Healthcare Providers to address the high healthcare costs of a small number of vulnerable patients. The Coalition brings together doctors, hospital staff, and social workers to provide coordinated care through teams that identify at-risk patients, address their medical and social needs, and help reduce emergency room visits and hospitalizations. Brenner has expanded this model to ten other communities across the U.S. and his collaborative approach is an important contribution to national healthcare reform discussions.
This article analyzes annual cost profiles and consumption patterns of Medicare beneficiaries with diabetes from 2000 to 2006. It finds that while the percentages of beneficiaries and expenditures in different consumption clusters (ranging from "crisis consumers" to "low consumers") remained generally constant year to year, there was significant movement of individuals between clusters over time. Notably, a large proportion of those in the lowest clusters in one year transitioned to the highest clusters in subsequent years, representing a significant portion of inpatient costs. This dynamic migration between clusters, with individuals moving from low to high usage, was a previously unrecognized trend with important implications for targeting of disease management programs.
This document proposes a medical cannabis clinical model program called Veterans for Compassionate Care (VFCC) in Washington State. The program would provide full medical and behavioral health services using cannabis, including growing pharmaceutical-grade cannabis. It aims to reduce opioid use and costs, provide jobs for veterans, and collect clinical data on cannabis therapies. The proposal requests state approval and funding to pilot the closed-loop clinical model program for qualifying patients like veterans with PTSD, chronic pain, and other conditions.
Effective Disease Management (DM) can improve the health of many Americans suffering from chronic illness while reducing costs to patients, health care providers, employers and more. Discover how use of DM from McKesson is helping to improve patient safety and medication safety.
The VA healthcare system is inefficient due to policies that resulted in veterans dying while waiting for appointments. An investigation found VA employees were falsifying appointment times. The VA's goal of seeing patients within 30 days is unacceptable compared to Medicare patients seeing doctors within 3 days. Two alternative policies are proposed to increase efficiency: 1) A hybrid system using Medicare for non-service related care and the VA for service-related care. 2) Removing priority groups 7 and 8 from VA healthcare to reduce wait times by 50% for service-disabled veterans in groups 1-6.
1) The document discusses how health information technology (HIT), such as electronic health records (EHRs) and health information exchanges (HIEs), has the potential to influence health reform efforts in the United States by reducing costs, increasing access to care, and improving quality of care.
2) The Affordable Care Act includes provisions and financial incentives to encourage widespread adoption of EHRs and use of HIT. Meaningful use criteria aim to ensure EHRs improve safety, quality, and coordination of care.
3) HIT such as EHRs and HIEs could transform healthcare by giving providers access to complete patient information, reducing medical errors, duplicative tests, and costs
Health Reform Alert - Implementation Guidance FAQsCBIZ, Inc.
The ACA’s governing agencies (Labor, HHS and IRS) have issued their 18th set of implementation FAQs, further defining certain aspects of the Affordable Care Act, as well as how the law coordinates with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Following are highlights of this guidance.
Learn more at www.cbiz.com
Meaningful Use and the Path to Population Health and Quality in a Transformin...Phytel
The over arching goal of the meaningful use requirements of the 2009 American Recovery and Reinvestment Act (ARRA) is to facilitate the transition to real quality improvement and population health management. Most physician practices will need supplemental information technology that automates the basic tasks of identifying, contacting, and tracking patients who need preventive and chronic care services, coupled with reports that care teams can use for quality improvement and reporting.
Jeffrey Brenner is a primary care physician in Camden, New Jersey who founded the Camden Coalition of Healthcare Providers to address the high healthcare costs of a small number of vulnerable patients. The Coalition brings together doctors, hospital staff, and social workers to provide coordinated care through teams that identify at-risk patients, address their medical and social needs, and help reduce emergency room visits and hospitalizations. Brenner has expanded this model to ten other communities across the U.S. and his collaborative approach is an important contribution to national healthcare reform discussions.
Michael Pelletier has over 40 years of experience in behavioral health administration and policy development. He has held several leadership roles within the Illinois Department of Human Services Division of Mental Health, including overseeing the closure of two state-operated psychiatric hospitals and developing community-based alternative care programs. Pelletier has extensive experience in hospital administration, strategic planning, program development, and contract management. He is skilled in maintaining regulatory compliance, performance management, and developing policies and procedures.
Chronic diseases are the leading cause of death in the US. Managed care organizations implement disease management programs like smoking cessation programs to help prevent chronic diseases and lower costs. These programs aim to eliminate risk factors for disease such as smoking and provide incentives, care management, and access to services to help patients quit smoking. Quality of care is evaluated through structure, process and outcomes to ensure these programs are effective.
1. Two states, South Carolina and Wisconsin, improved integration of PDMP data into electronic health systems by establishing connections between their PDMPs and various health IT platforms like EMR systems and pharmacy dispensing software.
2. States face challenges with PDMP integration like legal definitions of access, costs of integration projects, and establishing necessary agreements and user authorizations.
3. Florida operates drug surveillance systems through a medical examiners commission and PDMP. Analysis found declines in prescription opioid overdoses after implementation of legislative and regulatory interventions including a PDMP in 2011. However, heroin overdose deaths increased as some shifted to heroin.
Benefits of implementing_the_primary_care_pcmhVicki Harter
This document provides a review of cost and quality results from implementing the patient-centered medical home (PCMH) model of primary care. It summarizes newly reported and updated results from PCMH initiatives nationwide over the past two years. The results show that the PCMH improves health outcomes, enhances the patient and provider experience of care, and reduces unnecessary hospital and emergency department utilization, meeting the goals of better health, better care, and lower costs. The document defines key features of the PCMH model and provides data demonstrating how each feature contributes to these outcomes. It outlines growing private and public sector support for the PCMH in the United States.
Population Health Management & Meaningful UsePhytel
The government’s EHR incentive program is designed to transform healthcare delivery and dovetails with other healthcare reform initiatives. Population health management, the goal of these initiatives, requires advanced forms of health IT.
How to Manage Population Health Effectively in Accountable Care OrganizationsPhytel
The Affordable Care Act authorized a Medicare shared-savings program for accountable care organizations, and private payers are also contracting with ACOs. To succeed, ACOs must learn how to manage population health effectively.
Updated DOL Guidance on Mental Health Party & Addiction Equity Act.GerryLeske
The Department of Labor is targeting enforcement of mental health and substance use disorder laws. It recently issued guidance to help health plans comply with the Mental Health Parity and Addiction Equity Act, including proposed FAQs, a self-compliance tool, and a participant request form. The DOL conducted over 1,700 investigations since 2010 and found over 300 violations of parity laws.
Health Reform Bulletin 120 | Proposed Reliant Regulations.CBIZ, Inc.
The latest HRB provides insight into the following: Proposed Regulations: Expatriate Health Plans, Excepted Benefit Plans, Essential Health Benefits relating to Lifetime and Annual Limits, and Individual Shared Responsibility Requirements; IRS Releases Draft 2016 Forms 1094/1095.
The document outlines state responses to prescription drug and heroin abuse presented at an advocacy track session. It includes presentations from officials in Arizona, Virginia, and New Mexico on their state's strategies. Arizona's presentation focuses on the state's prescriber report cards. Virginia's presentation discusses the governor's task force recommendations and a new health and criminal justice data committee. New Mexico's presentation describes the state's high overdose rates and model of stakeholder collaboration to reduce overdose deaths.
The Michigan Primary Care Transformation Project (MiPCT) is a demonstration project testing the patient-centered medical home model across 350 primary care practices serving over 1.2 million patients in Michigan. Mercy Health Physician Partners participates in MiPCT and has seen improvements in care coordination and quality for patients. The program focuses on managing chronic illnesses, with over 50% of patients at one clinic having diabetes. Recommendations include expanding training on the patient-centered model to all staff, conducting patient surveys to assess quality, and establishing patient advisory councils.
Kansas' Data-Driven Prevention Initiative Program Data StrategyFan Xiong, M.P.H.
The Kansas Data-Driven Prevention Initiative aims to decrease opioid abuse and related health issues through enhanced surveillance of prescription drugs and heroin. The initiative will analyze syndromic surveillance and prescription drug monitoring program data to monitor trends in drug overdoses, develop a BRFSS module on opioid use disorders, and increase public health access to data for surveillance and evaluation. The overall goals are to reduce rates of opioid abuse, overdose deaths, and emergency department visits for opioids over the next 3 years.
This document discusses the challenges of being a multisite tumor navigator and provides case studies to illustrate these challenges. It notes that while small cancer programs may only be able to support one navigator, that navigator is then tasked with providing navigation across multiple sites. Case studies are presented of patients with various cancer types, and attendees are asked to consider navigation concerns and priorities for each patient. The document advocates for navigator specialization and identifies AONN as a potential platform for supporting multisite navigators through information sharing and networking.
The AbbVie Hepatitis C Community Educator (HCCE) program aimed to engage and activate patients previously diagnosed with HCV to discuss treatment options with a healthcare provider. The program enrolled over 7,000 patients from 2014-2015 through various channels. Community educators provided personalized support to enrolled patients to help overcome barriers to care. While one-third of enrolled patients were ultimately activated, educators faced challenges with patients facing multiple constraints and difficulties reaching patients consistently by phone. Access issues related to insurance policies and prior authorization also presented barriers to activating some patients.
The Affordable Care Act touches the lives of most Americans. In fact, nearly 21 million will be at risk if Obamacare is struck down, and may even lose health insurance completely if the law is ruled unconstitutional. This webinar will discuss what the outcome may be if ACA is repealed.
This document summarizes key points from a presentation on establishing survivorship programs. It discusses the need for navigation and survivorship care due to issues cancer survivors face. New CoC standards require navigation programs, survivorship care plans, and distress screening. A multi-disciplinary survivorship clinic example integrates navigation, medical, mental health and lifestyle support for survivors. Barriers include financial sustainability and changing provider mindsets. Success comes from collaboration, tailored care, and improving survivor well-being and care coordination.
140306 dr tim ferris healthcare cost challengeNuffield Trust
In this slideshow, Dr Tim Ferris, Vice President for Population Health Management, Partners HealthCare, and Medical Director of the Massachusetts General Physicians Organisation; explores a new approach to meeting the health care cost challenge.
Comparing Health Insurance Measurement Error (CHIME) in the ACS & CPSsoder145
This document summarizes a study that compared survey responses about health insurance from the American Community Survey (ACS) and Current Population Survey (CPS) to actual administrative insurance records to assess accuracy. The study found that both surveys produced reasonably accurate aggregated estimates but that some types of coverage, like direct purchase plans, were less accurately reported. Specifically:
- Both surveys had high sensitivity in detecting those with any insurance but the ACS performed better for direct purchase plans.
- The predictive power of reported coverage types varied, with direct purchase again less accurately predicted than employer-sponsored coverage.
- Prevalence estimates based on surveys were generally within a few percentage points of administrative records, though CPS estimates were less accurate for
The healthcare needs of the people have changed over time with the emergence of new ailments, and so has the healthcare industry. Following the steep rise in the cost of medical treatments, the necessity for some sort of cover to provide protection during a medical emergency has increased. Considering the changing lifestyle and needs of the people, the medical schemes in South Africa have also evolved over time.
A health insurance roadmap takes a look at some simple solutions to the complex issues facing health insurance, medicare, medicaid, long term care insurance, and the high cost of health expenses in retirement.
This will work because so much of this is already in place and a lot of the rest would be quick and easy to implement. As in all areas, knowledge is power. Consumers can take control of your insurance portfolio by becoming educated about insurance. Better education and understanding will lead to positive results for consumers and for the insurance industry.
Michael Pelletier has over 40 years of experience in behavioral health administration and policy development. He has held several leadership roles within the Illinois Department of Human Services Division of Mental Health, including overseeing the closure of two state-operated psychiatric hospitals and developing community-based alternative care programs. Pelletier has extensive experience in hospital administration, strategic planning, program development, and contract management. He is skilled in maintaining regulatory compliance, performance management, and developing policies and procedures.
Chronic diseases are the leading cause of death in the US. Managed care organizations implement disease management programs like smoking cessation programs to help prevent chronic diseases and lower costs. These programs aim to eliminate risk factors for disease such as smoking and provide incentives, care management, and access to services to help patients quit smoking. Quality of care is evaluated through structure, process and outcomes to ensure these programs are effective.
1. Two states, South Carolina and Wisconsin, improved integration of PDMP data into electronic health systems by establishing connections between their PDMPs and various health IT platforms like EMR systems and pharmacy dispensing software.
2. States face challenges with PDMP integration like legal definitions of access, costs of integration projects, and establishing necessary agreements and user authorizations.
3. Florida operates drug surveillance systems through a medical examiners commission and PDMP. Analysis found declines in prescription opioid overdoses after implementation of legislative and regulatory interventions including a PDMP in 2011. However, heroin overdose deaths increased as some shifted to heroin.
Benefits of implementing_the_primary_care_pcmhVicki Harter
This document provides a review of cost and quality results from implementing the patient-centered medical home (PCMH) model of primary care. It summarizes newly reported and updated results from PCMH initiatives nationwide over the past two years. The results show that the PCMH improves health outcomes, enhances the patient and provider experience of care, and reduces unnecessary hospital and emergency department utilization, meeting the goals of better health, better care, and lower costs. The document defines key features of the PCMH model and provides data demonstrating how each feature contributes to these outcomes. It outlines growing private and public sector support for the PCMH in the United States.
Population Health Management & Meaningful UsePhytel
The government’s EHR incentive program is designed to transform healthcare delivery and dovetails with other healthcare reform initiatives. Population health management, the goal of these initiatives, requires advanced forms of health IT.
How to Manage Population Health Effectively in Accountable Care OrganizationsPhytel
The Affordable Care Act authorized a Medicare shared-savings program for accountable care organizations, and private payers are also contracting with ACOs. To succeed, ACOs must learn how to manage population health effectively.
Updated DOL Guidance on Mental Health Party & Addiction Equity Act.GerryLeske
The Department of Labor is targeting enforcement of mental health and substance use disorder laws. It recently issued guidance to help health plans comply with the Mental Health Parity and Addiction Equity Act, including proposed FAQs, a self-compliance tool, and a participant request form. The DOL conducted over 1,700 investigations since 2010 and found over 300 violations of parity laws.
Health Reform Bulletin 120 | Proposed Reliant Regulations.CBIZ, Inc.
The latest HRB provides insight into the following: Proposed Regulations: Expatriate Health Plans, Excepted Benefit Plans, Essential Health Benefits relating to Lifetime and Annual Limits, and Individual Shared Responsibility Requirements; IRS Releases Draft 2016 Forms 1094/1095.
The document outlines state responses to prescription drug and heroin abuse presented at an advocacy track session. It includes presentations from officials in Arizona, Virginia, and New Mexico on their state's strategies. Arizona's presentation focuses on the state's prescriber report cards. Virginia's presentation discusses the governor's task force recommendations and a new health and criminal justice data committee. New Mexico's presentation describes the state's high overdose rates and model of stakeholder collaboration to reduce overdose deaths.
The Michigan Primary Care Transformation Project (MiPCT) is a demonstration project testing the patient-centered medical home model across 350 primary care practices serving over 1.2 million patients in Michigan. Mercy Health Physician Partners participates in MiPCT and has seen improvements in care coordination and quality for patients. The program focuses on managing chronic illnesses, with over 50% of patients at one clinic having diabetes. Recommendations include expanding training on the patient-centered model to all staff, conducting patient surveys to assess quality, and establishing patient advisory councils.
Kansas' Data-Driven Prevention Initiative Program Data StrategyFan Xiong, M.P.H.
The Kansas Data-Driven Prevention Initiative aims to decrease opioid abuse and related health issues through enhanced surveillance of prescription drugs and heroin. The initiative will analyze syndromic surveillance and prescription drug monitoring program data to monitor trends in drug overdoses, develop a BRFSS module on opioid use disorders, and increase public health access to data for surveillance and evaluation. The overall goals are to reduce rates of opioid abuse, overdose deaths, and emergency department visits for opioids over the next 3 years.
This document discusses the challenges of being a multisite tumor navigator and provides case studies to illustrate these challenges. It notes that while small cancer programs may only be able to support one navigator, that navigator is then tasked with providing navigation across multiple sites. Case studies are presented of patients with various cancer types, and attendees are asked to consider navigation concerns and priorities for each patient. The document advocates for navigator specialization and identifies AONN as a potential platform for supporting multisite navigators through information sharing and networking.
The AbbVie Hepatitis C Community Educator (HCCE) program aimed to engage and activate patients previously diagnosed with HCV to discuss treatment options with a healthcare provider. The program enrolled over 7,000 patients from 2014-2015 through various channels. Community educators provided personalized support to enrolled patients to help overcome barriers to care. While one-third of enrolled patients were ultimately activated, educators faced challenges with patients facing multiple constraints and difficulties reaching patients consistently by phone. Access issues related to insurance policies and prior authorization also presented barriers to activating some patients.
The Affordable Care Act touches the lives of most Americans. In fact, nearly 21 million will be at risk if Obamacare is struck down, and may even lose health insurance completely if the law is ruled unconstitutional. This webinar will discuss what the outcome may be if ACA is repealed.
This document summarizes key points from a presentation on establishing survivorship programs. It discusses the need for navigation and survivorship care due to issues cancer survivors face. New CoC standards require navigation programs, survivorship care plans, and distress screening. A multi-disciplinary survivorship clinic example integrates navigation, medical, mental health and lifestyle support for survivors. Barriers include financial sustainability and changing provider mindsets. Success comes from collaboration, tailored care, and improving survivor well-being and care coordination.
140306 dr tim ferris healthcare cost challengeNuffield Trust
In this slideshow, Dr Tim Ferris, Vice President for Population Health Management, Partners HealthCare, and Medical Director of the Massachusetts General Physicians Organisation; explores a new approach to meeting the health care cost challenge.
Comparing Health Insurance Measurement Error (CHIME) in the ACS & CPSsoder145
This document summarizes a study that compared survey responses about health insurance from the American Community Survey (ACS) and Current Population Survey (CPS) to actual administrative insurance records to assess accuracy. The study found that both surveys produced reasonably accurate aggregated estimates but that some types of coverage, like direct purchase plans, were less accurately reported. Specifically:
- Both surveys had high sensitivity in detecting those with any insurance but the ACS performed better for direct purchase plans.
- The predictive power of reported coverage types varied, with direct purchase again less accurately predicted than employer-sponsored coverage.
- Prevalence estimates based on surveys were generally within a few percentage points of administrative records, though CPS estimates were less accurate for
The healthcare needs of the people have changed over time with the emergence of new ailments, and so has the healthcare industry. Following the steep rise in the cost of medical treatments, the necessity for some sort of cover to provide protection during a medical emergency has increased. Considering the changing lifestyle and needs of the people, the medical schemes in South Africa have also evolved over time.
A health insurance roadmap takes a look at some simple solutions to the complex issues facing health insurance, medicare, medicaid, long term care insurance, and the high cost of health expenses in retirement.
This will work because so much of this is already in place and a lot of the rest would be quick and easy to implement. As in all areas, knowledge is power. Consumers can take control of your insurance portfolio by becoming educated about insurance. Better education and understanding will lead to positive results for consumers and for the insurance industry.
Secada_Francis - Public Campaign - Final ProjectFrancis Secada
This campaign seeks to increase annual health screenings among young insured adults. A survey found that having insurance does not necessarily lead people to have a regular doctor or get screenings. The campaign will target ages 25-39 in major cities through ads on commutes and in stores. Ads will emphasize that screenings are free and finding a doctor is easy using a new app. The app helps users find doctors and schedule appointments to get screenings, with the goal of catching health issues early when treatment is cheaper and safer. The campaign aims to change the behavior of using insurance for preventive care by making the process simple and emphasizing long-term health benefits.
In July 2018, NITI Aayog published a Strategy and Approach document on the National Health Stack. The document underscored the need for Universal Health Coverage (UHC) and laid down the technology framework for implementing the Ayushman Bharat programme which is meant to provide UHC to the bottom 500 million of the country. While the Health Stack provides a technological backbone for delivering affordable healthcare to all Indians, we, at iSPIRT, believe that it has the potential to go beyond that and to completely transform the healthcare ecosystem in the country. We are indeed headed for a health leapfrog in India! Over the last few months, we have worked extensively to understand the current challenges in the industry as well as the role and design of individual components of the Health Stack. In this post, we elaborate on the leapfrog that will be enabled by blending this technology with care delivery.
Selecting an appropriate medical insurance plan in Singapore is a deliberate and meticulous undertaking that necessitates careful examination of various elements. For more information visit the page!
This document discusses critical illness plans, also known as catastrophic health insurance plans, as a lower-cost alternative to traditional health insurance. These plans offer lower monthly premiums but higher out-of-pocket costs. They are best suited for generally healthy individuals seeking protection from catastrophic health issues like cancer, heart attacks, or strokes. These plans effectively lower costs for individuals with lower incomes, the self-employed, or those whose jobs do not provide health insurance.
The Proposed Health Care Reform’S Impact On MarketingStone Ward
The document summarizes key aspects of the proposed US health care reform plan, including:
1) It would require all Americans to have health insurance and businesses to provide it or pay a penalty. Subsidies would help lower-income families purchase insurance.
2) Health insurance exchanges would be created to allow consumers to compare plans starting in 2013.
3) While hospitals, doctors, and private Medicare plans oppose aspects of the plan, supporters argue it will reduce costs and improve care by covering more of the uninsured.
A guide to Hong Kong's voluntary health insurance schemeIulianaVelinskiy
The Voluntary Health Insurance Scheme (VHIS) in Hong Kong aims to enhance protection for hospital insurance, provide additional private healthcare options, and reduce pressure on public hospitals. It regulates individual indemnity hospital insurance and allows people to use private or public facilities. There are two plan types - standard and flexi - which offer basic and enhanced medical coverage respectively. Insurance premiums vary by age, gender, and medical history.
This document discusses workplace wellness programs and their potential to reduce workers' compensation costs by addressing employees' overall health issues. It also provides examples of strategies that have been shown to successfully contain health care costs for public sector employers. Key points include the importance of integrating efforts to manage medical and workers' compensation costs, and examples from Indiana of savings achieved through consumer-driven health plans that encourage preventive care and cost-conscious decision making.
The document discusses the history and current state of the Medicare coverage gap, also known as the "doughnut hole." It describes how the Affordable Care Act aims to gradually close the gap by 2020 through discounts on brand name drugs and increased coverage each year. However, some argue that 10 years is too long to close the gap and more needs to be done to help those who currently struggle to afford their medications. The implications of closing the gap on health, economic, and political factors are also examined.
ACA (Affordable care Act) signed by Obama on 23 march 2010. .pdfannaistrvlr
ACA (Affordable care Act) signed by Obama on 23 march 2010. Putting
Information for Consumers Online So that consumers can compare health insurance coverage
options and pick the coverage that works for them. Prohibiting Denying Coverage of Children
Based on PreExisting Conditions The health care law includes new rules to prevent insurance
companies from denying coverage to children under the age of 19 due to a pre-existing
condition. Prohibiting Insurance Companies from Rescinding Coverage In the past, insurance
companies could search for an error, or other technical mistake, on a customer\'s application and
use this error to deny payment for services when he or she got sick. But now this is illegal. After
media reports cited incidents of breast cancer patients losing coverage, insurance companies
agreed to end this practice immediately. Eliminating Lifetime Limits on Insurance Coverage
Insurance companies will be prohibited from imposing lifetime dollar limits on essential
benefits, like hospital stays. Regulating Annual Limits on Insurance Coverage Insurance
companies\' use of annual dollar limits on the amount of insurance coverage a patient may
receive will be restricted for new plans in the individual market and all group plans. In 2014, the
use of annual dollar limits on essential benefits like hospital stays will be banned for new plans
in the individual market and all group plans. Appealing Insurance Company Decisions
Provides consumers with a way to appeal coverage determinations or claims to their insurance
company, and establishes an external review process. Establishing Consumer Assistance
Programs in the States States that apply ACA receive federal grants to help set up or expand
independent offices to help consumers navigate the private health insurance system. These
programs help consumers file complaints and appeals; enroll in health coverage; and get
educated about their rights and responsibilities in group health plans or individual health
insurance policies. The programs will also collect data on the types of problems consumers have,
and file reports with the U.S. Department of Health and Human Services to identify trouble spots
that need further oversight. Improving Quality and lowering costs Both this head get
amended from time to time so that consumer receive best to best service. Increasing Access to
Affordable Care Hoe ACA Affects Reiumburshment Short Term Effects:
The most immediate expected effect of the ACA for providers is a sudden rise in patient
populations. Millions of Americans are expected to obtain coverage under the ACA
Payers are required to cover more than ever,under the ACA, individual and small group health
plans are required to cover 10 essential health benefits Long Term Effects:
Changing payment and care models,biggest changes in healthcare right now are the new fee-for-
value payment models that are replacing traditional fee-for-service programs Through
Medicare and Medicaid, the government has been .
Week #5-To Do List-CCHWeek 5 IntroductionIntroduction To Co.docxcelenarouzie
Week #5-To Do List-CCH
Week 5: Introduction
Introduction To Compliance Documentation & Reporting
Proper documentation is an inherent component of delivery of care, not an add-on. One of the oldest battles in healthcare is that between the hospital Medical Records department and the admitting Physician to complete necessary documentation for the Patient’s Chart. The most common cause of loss of admitting privileges has been from this source. This process has only become more important and necessary with the increasing recognition of the importance of proper documentation for legal and ethical defense purposes.
Documentation also serves a number of financial aspects of patient care delivery, including billing, grant writing for research projects, medical research to discover future tests, procedures, and cures, and funding for government supported agencies and programs.
Objectives
To successfully complete this learning unit, you will be expected to:
Identify the uses for health care documentation.
Learn the essential components of quality documentation.
Categorize the document guidelines under the federal False Claims Act.
Identify the documentation required for compliance under the Federal Stark Law.
List the aspects of documentation compliance with regard to electronic health records.
Identify the important issues regarding ethical coding practices.
Learn the most common illegal practices for HIM reporting.
Identify the key concerns under the federal False Claims Act that relate to reporting.
Determine the impact of the Physician Quality Reporting Initiative (PQRI) on HIM processes in physicians’ offices.
Identify the circumstances in which a health care professional is mandated to report a patient’s diagnosis.
Week 5: Discussion
Answer the following questions:
Review the various uses for health care documentation and discuss how each has an impact on the health care delivery system
Discuss procedures you might enact in your facility to avoid violating the False Claims Act
Discuss why physician offices should participate in PQRI
Week 5: Case Study Assignment
Please read and choose one of the following case studies:
Case study on page 111 of your textbook. (This Case Study is in the section for Securing EHR and starts with "NOTE: In each CMP (Civil Monetary Penalties) case resolved through a settlement agreement, . . . ")
Case study on page 127 of your textbook. (This Case Study is in the section for Phantom Patients and starts with "Two Charged in False Claims to Medicaid."
Case study on page 128 of your textbook. (This Case Study is in the section for Services not Performed and starts with "WASHINGTON—April 14, 2008—A board-certified radiologist, Fred Steinberg, M.D., his imaging centers . . ."
Case study on page 131 of your textbook. (This Case Study is in the section for Upcoding and starts with "July 2007: In Florida, a doctor was sentenced to 78 months in prison .
The document discusses potential litigation risks insurers may face related to implementation of the Affordable Care Act (ACA). It identifies two key expectations that may drive litigation if unfulfilled: 1) that everyone will have guaranteed, robust health insurance coverage; and 2) that costs associated with health insurance will stabilize or decrease over time. The document outlines four specific risk areas where insurers could face legal challenges, including challenges to benefit determinations and scope of coverage, issues related to the establishment of insurance exchanges, disputes over medical loss ratio calculations and rebates, and challenges to insurers' risk adjustment calculations. It concludes that insurers should plan ahead for potential litigation challenges as key ACA reforms are implemented.
Chapter 18 Private and Government Healthcare Systems PriMorganLudwig40
Chapter 18
Private and Government Healthcare Systems
Private and Government Healthcare Systems
In the United States, health insurance coverage is generally classified as either private (non-government) coverage or government-sponsored coverage.
Healthcare Coverage vs. Uninsured
The National Center for Health Statistics defines health insurance as public and private payers who cover medical expenditures incurred by a defined population in a variety of settings.
In the United States, the risk of becoming uninsured increases significantly for those earning low wages, the unemployed, and when employers are unable to provide insurance to workers.
Table 5-2 presents the trend of declining health insurance coverage.
Private Health Insurance
The concept of insurance is to combine the healthcare experiences of many enrollees in order to reduce expenses for any one individual to a manageable prepayment amount.
Employment-Based Plans is coverage offered through one’s own employment or a relative’s employment.
It may be offered by an employer or by a union.
Private Health Insurance Continued
Direct-Purchase/Fee-For-Service Plans are the traditional type of healthcare policy.
The physician sets a price for each type of service delivered, and then the client or insurance company pays the fee.
This type of health insurance provides the most choices of doctors and hospitals.
Private Health Insurance Continued
The two kinds of fee-for-service coverage are basic and major medical.
Basic covers some hospital services and supplies, such as X-rays and prescribed medicine.
Major medical insurance covers the cost of long-term, high-cost illnesses or injuries plus whatever basic did not cover.
Private Health Insurance Continued
Group Contract Insurance—to make hospitals and physicians products and services affordable to ordinary people in the United States.
With unmanaged care (fee-for-service) payments, healthcare providers could increase the number of single services they deliver in order to increase profit.
Private Health Insurance Continued
Managed Care—manages the cost and delivery of healthcare services, the quality of that healthcare, and access to care.
Managed care influences how much healthcare clients can use.
Health Maintenance Organizations (HMOs) are prepaid health plans.
The goal of an HMO is to provide affordable, well-organized healthcare by allowing clients to prepay (capitation payment) on a regular monthly basis for all services provided.
Private Health Insurance Continued
Including physicians’ visits, hospital stays emergency care, surgery, laboratory (lab) tests, X-rays, and therapy for all members and their families.
There may be a small co-payment for each office visit, such as $15 for a doctor’s visit or $50 for hospital emergency room treatment.
Private Health Insurance Continued
Point-of-Service Plans (POS) offer enrollees the option of receiving services from participating or nonparticipating prov ...
This document discusses several common payment mechanisms used in the US healthcare system, including Medicaid/Medicare, out-of-pocket expenses, and preferred provider organizations (PPOs). Medicaid/Medicare accounts for a large portion of US healthcare spending and debt. Patients are also responsible for out-of-pocket costs like co-payments that are rising faster than incomes. PPOs allow patients to choose providers both in and out of their insurance network, and these plans are becoming more popular for Medicare recipients. Billing and payment collection are essential to fund the entire healthcare system.
1) Healthcare demand is rising due to increasing rates of preventable illness and suboptimal use of healthcare resources influenced by consumer choices. Obesity rates in the US have led to increased chronic diseases and healthcare costs.
2) Healthcare demand differs from other services in that health outcomes cannot be standardized, consumers have limited choice in providers, and payment usually comes from third parties rather than consumers directly.
3) Consumers do not always make rational decisions regarding healthcare. They may seek emergency care for minor issues, be overwhelmed by excessive insurance options, or rely too heavily on provider recommendations without understanding implications.
An impoverished man is diagnosed with cancer of the.docxwrite12
An impoverished 69-year-old man is diagnosed with pancreatic cancer. Doctors face an ethical dilemma as chemotherapy may extend his life by a few months but cost $150,000. Meanwhile, a health department proposes free education to prevent pancreatic cancer in many people through reducing alcohol consumption. This scenario highlights the complex trade-offs between costs and benefits of both individual treatment and population-level prevention.
LECTUREUnit ObjectivesAfter completing this unit, you should b.docxgauthierleppington
LECTURE
Unit Objectives
After completing this unit, you should be able to
define
moral hazard
,
adverse selection
, and
cost-shifting
identify the major public programs for the financing of health care
compare and contrast Medicare and Medicaid
list and describe the four sub-programs of Medicare
describe different reimbursement approaches for health services
Unit Lecture
When asked how health care services are paid for, many of us think immediately of health insurance. However, we typically don't think about the dynamics behind health insurance or the various types of programs through which it is delivered. At its most basic level,
health insurance
is a tool for mitigating risk. An individual purchases health insurance to mitigate the risk of having to pay an enormous medical bill in the event of sickness or injury.
Those who provide health insurance—insurance companies—also work to mitigate risk, albeit from the other side. They attempt to create a risk pool containing a large number of healthy people to offset the expenses accrued by those who do get sick or injured.
Premiums
, the fees paid for ownership of health insurance, are used to subsidize the cost of the health care provided to those who use the insurance.
Factors that insurance companies need to be mindful of include
moral hazard
, whereby an insured individual is more prone to seek care than if he or she were paying the medical bill him- or herself; and
adverse selection
, whereby insurance is mainly purchased by those most in need of it. As with any financial enterprise, if the costs of providing the product or service exceed the revenue, the company goes out of business.
There are several types of insurance programs, both public and private. Together, these programs cover not only individual health services, but public health services, research, and the administration of the delivery and financing of health care in the United States. The majority of public and private expenditures—approximately 81 percent—are directed toward hospital care, provider and clinical services, long-term care, and prescription drug provision (Kovner & Knickman, 2011).
As mentioned in the week 4 lecture, health insurance is a relatively new mechanism for financing health services, and it has grown substantially since the mid-1900s, when only 9 percent of the US population had health insurance (Blumberg & Davidson, 2009). Health insurance can be broken down into private and public insurance.
Private health insurance
is primarily employment-based, meaning that individuals receive coverage through commercial health insurance plans for which their employers either pay the premiums or subsidize them, with the employee paying the balance.
Some larger employers choose to self-insure, which means that they administer their own plans and accept the financial risk of doing so. In essence, they act as the insurer of their employees.
Some individuals, either through necessity or choice, opt to purchase t.
Similar to An ACS CAN Examination of Short-Term Health Plans (20)
The world stands to lose close to 10% of total economic value by mid-century if climate change stays on the currently-anticipated trajectory, and the Paris Agreement and 2050 net-zero emissions targets are not met.
Many emerging markets have most to gain if the world is able to rein in temperature gains. For example, action today to get back to the Paris temperature rise scenario would mean economies in southeast Asia could prevent around a quarter of the gross domestic product (GDP) loss by mid-century that they may otherwise suffer. Our analysis in this report is unique in explicitly simulating for the many uncertainties around the impacts of climate change. It shows that those economies most vulnerable to the potential physical risks of climate change stand to benefit most from keeping temperature rises in check. This includes some of the world's most dynamic emerging economies, the engines of global growth in the years to come. The message from the analysis is clear: no action on climate change is not an option.
Promise and peril: How artificial intelligence is transforming health careΔρ. Γιώργος K. Κασάπης
AI has enormous potential to improve the quality of health care, enable early diagnosis of diseases, and reduce costs. But if implemented incautiously, AI can exacerbate health disparities, endanger patient privacy, and perpetuate bias. STAT, with support from the Commonwealth Fund, explored these possibilities and pitfalls during the past year and a half, illuminating best practices while identifying concerns and regulatory gaps. This report includes many of the articles we published and summarizes our findings, as well as recommendations we heard from caregivers, health care executives, academic experts, patient advocates, and others.
In 2020, Amnesty International recorded the lowest number of executions in over a decade at 483. This was a 26% decrease from 2019. Four countries - Iran, Egypt, Iraq and Saudi Arabia - accounted for 88% of all recorded executions. The global number of known death sentences also decreased by 36% compared to 2019, partly due to disruptions from the Covid-19 pandemic. However, some countries like Egypt more than tripled their executions and the US resumed federal executions after a 17-year hiatus, putting 10 men to death over 5 months. Overall, the report found that the trend towards global abolition of the death penalty continued in 2020, but the pandemic exacerbated the cruelty of capital punishment in some retaining
Aviva’s first How We Live report was published in September 2020 when the world was firmly in the grip of a global pandemic. In the UK the vaccination programme is well underway and the mood of the nation is hopeful. This latest How We Live report looks at the long-term effects of the Coronavirus outbreak and considers its impact on our future behaviours.
We interviewed 4,000 adults across the UK to gather their views on a wide range of lifestyle decisions including property priorities, home-working, green living, career paths, vehicle choices and holiday plans. We also asked whether people had experienced any positive outcomes from the Covid pandemic. This report considers the practical and emotional skills which have been fostered as a result. Since the beginning of 2020, the UK has seen immense change. As we look forward to a sense of “normality” it remains to be seen which aspects of life will return to their previous states, and where we can expect changes to become permanent fixtures.
The life insurance industry provides protection against the financial consequences of the premature death of a family breadwinner, disability, or outliving one’s retirement assets. But how are life insurance products actually designed and priced?
Product committees comprising agents, underwriters, actuaries, and senior management sit and discuss what new products should be offered. The agents have vast experience visiting with policyholders to determine their needs. Underwriters set the guidelines on which policyholders will be accepted and/or rated. Smart actuaries (while most would find this redundant, some would call it an oxymoron) assess the potential risks in these products and set a potential price. Senior management listens to agents, underwriters, and actuaries and helps finalize the product design, the guidelines for accepting risks, and the price. The programmers will also have to be contacted to determine the cost of administering the products. Many iterations of these discussions may take place before a product is ready for sale. The entire process could take up to a year.
Some of these products are quite complex, taking into account long-term interest rates and probabilities of death/survival, disability, and lapse. With this lengthy and rigorous process, one would imagine that few mistakes are made. However, this is not the case. What follows are a few examples of major product mistakes which cost the life insurance industry a lot of time, money, and bad publicity.
The COVID-19 pandemic and subsequent lockdowns forced many insurers to accelerate the transition to digital business models. In many countries, this transition has been remarkably successful, however, the crisis also highlighted the critical role played by national regulatory frameworks in both hindering and facilitating the shift to digitalisation in the insurance industry. COVID-19 lockdowns highlighted the critical role of national regulatory frameworks in both hindering and facilitating the shift to digitalisation in the insurance industry. Digitalisation is not a goal in itself, but provides insurers and their customers with benefits that are particularly useful in situations where in-person interactions cannot take place, played out in its fullest form during the COVID-19-induced lockdowns. Digitalisation drives an increase in speed and efficiency, irrespective of where the customer is located, and promises improved customer service and satisfaction.
The document discusses the Internet of Things (IoT) and its implications for insurance. It notes that as more "things" become connected to the internet and collect data, this creates opportunities for new types of insurance products based on device interactions and data-driven risk assessments. However, it also raises issues around data integrity, privacy, security and regulation that must be addressed. The insurance industry could gain over $1 trillion in new premiums if it properly manages risks related to data, cybersecurity, cloud computing and more.
The rapid rise of online political campaigning has made most political financing regulations obsolete, putting transparency and accountability at risk. Seven in 10 countries worldwide do not have any specific limits on online spending on election campaigns, with six out of 10 not having any restrictions on online political advertising at all.
Highlights
• On average, concerns over Innovation was ranked highest, followed by Implications of Covid-19 • Respondents indicated innovation is important, but are mostly in process
• Respondents were mostly confident in implementing their innovation plans.
• Nearly half of respondents indicated their focus was on the customer experience • Most respondents expect some negative impact from Covid-19, with decreased profit indicated most, followed by decreased sales effectiveness, which are likely related
• The most common change in response to the Covid-19 impact were workplace and staffing changes, followed by technology investments
• Of the respondents, 92% indicated cyber security was important or very important.
• Continuous effort was ranked highest, and Mitigating internal threats, Identifying external threats, and Prioritizing identifying cyber risks were ranked next.
• While 95% of respondents indicated emerging threats were important or very important, 28% Indicated they were very good at responding to them
• For resiliency and sustainability, corporate ESG and R&S for internal operations were ranked as the highest priorities
iis the institutes innovation covid-19
What North America’s top finance executives are thinking - and doingΔρ. Γιώργος K. Κασάπης
Each quarter (since 2Q10), CFO Signals has tracked the thinking and actions of CFOs representing many of North America’s largest and most influential companies. All respondents are CFOs from the US, Canada, and Mexico, and the vast majority are from companies with more than $1 billion in annual revenue. The 1Q 2021 survey was open from February 8-19, 2021. A total of 128 CFOs participated, 69% from public companies and 31% from privately held companies.
Democratic watchdog organization Freedom House has released its annual ranking of the world's most free and most suppressed nations.
The report is a key barometer for global democracy and this year's edition found that global freedom has declined for the 15th straight year. 2020 was a turbulent year with the pandemic, violent conflict and economic and physical insecurity leading to democracy's defenders sustaining heavy losses against authoritarian foes which has resulted in a shift in the internatioal baance in favor of tyranny.
A total of 195 countries and 15 territories were analyzed on their levels of access to political rights and civil liberties with the number experiencing a deterioration in their freedom scores exceeding the number that saw improvement by the widest margin since 2006. In 2020, nearly 75 percent of the world's population lived under a government that saw its democracy score decline in the past year.
Women, Business and the Law 2021 is the seventh in a series of annual studies measuring the laws and regulations that affect women’s economic opportunity in 190 economies. Amidst a global pandemic that threatens progress toward gender equality, the report identifies barriers to women’s economic participation and encourages reform of discriminatory laws. This year, the study also includes important findings on government responses to the COVID-19 crisis and pilot research related to childcare and women’s access to justice.
Strong competition undoubtedly contributes to a country’s productivity and economic growth. The primary objective of a competition policy is to enhance consumer welfare by promoting competition and controlling practices that could restrict it. More competitive markets stimulate innovation and generally lead to lower prices for consumers, increased product variety and quality, more entry and enhanced investment. Overall, greater competition is expected to deliver higher levels of welfare and economic growth.
Long-erm Care and Health Care Insurance in OECD and Other CountriesΔρ. Γιώργος K. Κασάπης
This report carries out a stocktaking of what systems have in OECD and non-OECD countries for longterm care and health care, as well as the types of insurance products that are made available in these countries. It is part of a broader project that examines the complementarity of the social security network with the private insurance market, which examines how insurance could support the public sector longterm care and health care systems, as well as considering the financing of long-term care and health care.
This tenth edition of Global Insurance Market Trends provides an overview of market trends to better understand the overall performance and health of the insurance market. This monitoring report is compiled using data from the OECD Global Insurance Statistics (GIS) exercise. The OECD has collected and analysed data on insurance in OECD countries, such as the number of insurance companies and employees, insurance premiums and investments by insurance companies, dating back to the 1980s. Over time, the framework of this exercise has expanded and now includes key items of the balance sheet and income statement of direct insurers and reinsurers.
Does AI threaten and undermine human value in the workplace more than any other technology? There have been significant advances in AI, but will their impact really be different this time?
This literature review takes stock of what is known about the impact of artificial intelligence on the labour market, including the impact on employment and wages, how AI will transform jobs and skill needs, and the impact on the work environment. The purpose is to identify gaps in the evidence base and inform future research on AI and the labour market.
The OECD has estimated that 14% of jobs are at high risk of automation.
•Despite this, employment grew in nearly all OECD countries over the period 2012-2019.
•At the country level, a higher risk of automation was associated with higher employment growth over the period. This might be because automation promotes employment growth by increasing productivity, although other factors are also at play.
•At the occupational level, however, employment growth was much lower in occupations at high risk of automation (6%) than in occupations at low risk (18%).
•Low-educated workers were more concentrated in high-risk occupations in 2012 and have become even more concentrated in these occupations since then.
•The low growth in jobs in high risk occupations has not led to a drop in the employment rate of low-educated workers. This is largely because the number of workers with a low education has fallen in line with the demand for these workers.
•Going forward, however, the risk of automation is increasingly falling on low-educated workers and the COVID-19 crisis is likely to accelerate automation, as companies reduce reliance on human labour and contact between workers, or re-shore some production.
Prescription drug prices in U.S. more than 2.5 times higher than in other cou...Δρ. Γιώργος K. Κασάπης
Prescription drugs cost an average of 2.56 times more in the United States than they do in 32 other countries, according to a new report from RAND Corporation.
That disparity is even greater for brand name drugs, with U.S. prices averaging 3.44 times those in comparison nations. The study also found that prices for unbranded generic drugs — which account for 84% of drugs sold in the United States by volume but only 12% of U.S. spending — are slightly lower in the United States than in most other countries.
‘A circular nightmare’: Short-staffed nursing homes spark Covid-19 outbreaks,...Δρ. Γιώργος K. Κασάπης
Nursing homes have suffered grievously in the coronavirus pandemic. Chronically understaffed, that’s getting worse, a new US Pirg Education Fund analysis says. The shortage of direct-care workers rose from 20% of U.S. nursing homes in May to 23% in December. Too few workers raises stress among staff, the authors argue, making them and the residents they care for more vulnerable to Covid-19 infections, reducing staff further in “a circular nightmare.”
This document analyzes the impacts of utility disconnection and eviction moratoria policies on COVID-19 infections and deaths across US counties. It finds that policies limiting evictions reduced COVID-19 infections by 3.8% and deaths by 11%, while moratoria on utility disconnections reduced infections by 4.4% and deaths by 7.4%. Had these policies been adopted nationwide, infections could have been reduced up to 14.2% and deaths up to 40.7% with eviction moratoria, and infections reduced up to 8.7% and deaths up to 14.8% with utility disconnection moratoria. The document provides background on housing precarity and heterogeneity in government COVID-
Michigan HealthTech Market Map 2024. Includes 7 categories: Policy Makers, Academic Innovation Centers, Digital Health Providers, Healthcare Providers, Payers / Insurance, Device Companies, Life Science Companies, Innovation Accelerators. Developed by the Michigan-Israel Business Accelerator
Hypertension and it's role of physiotherapy in it.Vishal kr Thakur
This particular slides consist of- what is hypertension,what are it's causes and it's effect on body, risk factors, symptoms,complications, diagnosis and role of physiotherapy in it.
This slide is very helpful for physiotherapy students and also for other medical and healthcare students.
Here is summary of hypertension -
Hypertension, also known as high blood pressure, is a serious medical condition that occurs when blood pressure in the body's arteries is consistently too high. Blood pressure is the force of blood pushing against the walls of blood vessels as the heart pumps it. Hypertension can increase the risk of heart disease, brain disease, kidney disease, and premature death.
Sectional dentures for microstomia patients.pptxSatvikaPrasad
Microstomia, characterized by an abnormally small oral aperture, presents significant challenges in prosthodontic treatment, including limited access for examination, difficulties in impression making, and challenges with prosthesis insertion and removal. To manage these issues, customized impression techniques using sectional trays and elastomeric materials are employed. Prostheses may be designed in segments or with flexible materials to facilitate handling. Minimally invasive procedures and the use of digital technologies can enhance patient comfort. Education and training for patients on prosthesis care and maintenance are crucial for compliance. Regular follow-up and a multidisciplinary approach, involving collaboration with other specialists, ensure comprehensive care and improved quality of life for microstomia patients.
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - ...rightmanforbloodline
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - 34.
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - 34.
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - 34.
R3 Stem Cell Therapy: A New Hope for Women with Ovarian FailureR3 Stem Cell
Discover the groundbreaking advancements in stem cell therapy by R3 Stem Cell, offering new hope for women with ovarian failure. This innovative treatment aims to restore ovarian function, improve fertility, and enhance overall well-being, revolutionizing reproductive health for women worldwide.
Digital Health in India_Health Informatics Trained Manpower _DrDevTaneja_15.0...DrDevTaneja1
Digital India will need a big trained army of Health Informatics educated & trained manpower in India.
Presently, generalist IT manpower does most of the work in the healthcare industry in India. Academic Health Informatics education is not readily available at school & health university level or IT education institutions in India.
We look into the evolution of health informatics and its applications in the healthcare industry.
HIMMS TIGER resources are available to assist Health Informatics education.
Indian Health universities, IT Education institutions, and the healthcare industry must proactively collaborate to start health informatics courses on a big scale. An advocacy push from various stakeholders is also needed for this goal.
Health informatics has huge employment potential and provides a big business opportunity for the healthcare industry. A big pool of trained health informatics manpower can lead to product & service innovations on a global scale in India.
Fit to Fly PCR Covid Testing at our Clinic Near YouNX Healthcare
A Fit-to-Fly PCR Test is a crucial service for travelers needing to meet the entry requirements of various countries or airlines. This test involves a polymerase chain reaction (PCR) test for COVID-19, which is considered the gold standard for detecting active infections. At our travel clinic in Leeds, we offer fast and reliable Fit to Fly PCR testing, providing you with an official certificate verifying your negative COVID-19 status. Our process is designed for convenience and accuracy, with quick turnaround times to ensure you receive your results and certificate in time for your departure. Trust our professional and experienced medical team to help you travel safely and compliantly, giving you peace of mind for your journey.www.nxhealthcare.co.uk
This particular slides consist of- what is Pneumothorax,what are it's causes and it's effect on body, risk factors, symptoms,complications, diagnosis and role of physiotherapy in it.
This slide is very helpful for physiotherapy students and also for other medical and healthcare students.
Here is a summary of Pneumothorax:
Pneumothorax, also known as a collapsed lung, is a condition that occurs when air leaks into the space between the lung and chest wall. This air buildup puts pressure on the lung, preventing it from expanding fully when you breathe. A pneumothorax can cause a complete or partial collapse of the lung.
CHAPTER 1 SEMESTER V COMMUNICATION TECHNIQUES FOR CHILDREN.pdfSachin Sharma
Here are some key objectives of communication with children:
Build Trust and Security:
Establish a safe and supportive environment where children feel comfortable expressing themselves.
Encourage Expression:
Enable children to articulate their thoughts, feelings, and experiences.
Promote Emotional Understanding:
Help children identify and understand their own emotions and the emotions of others.
Enhance Listening Skills:
Develop children’s ability to listen attentively and respond appropriately.
Foster Positive Relationships:
Strengthen the bond between children and caregivers, peers, and other adults.
Support Learning and Development:
Aid cognitive and language development through engaging and meaningful conversations.
Teach Social Skills:
Encourage polite, respectful, and empathetic interactions with others.
Resolve Conflicts:
Provide tools and guidance for children to handle disagreements constructively.
Encourage Independence:
Support children in making decisions and solving problems on their own.
Provide Reassurance and Comfort:
Offer comfort and understanding during times of distress or uncertainty.
Reinforce Positive Behavior:
Acknowledge and encourage positive actions and behaviors.
Guide and Educate:
Offer clear instructions and explanations to help children understand expectations and learn new concepts.
By focusing on these objectives, communication with children can be both effective and nurturing, supporting their overall growth and well-being.
CHAPTER 1 SEMESTER V COMMUNICATION TECHNIQUES FOR CHILDREN.pdf
An ACS CAN Examination of Short-Term Health Plans
1. Inadequate Coverage: An ACS CAN Examination of Short-Term
Health Plans
May 13, 2019
Executive Summary
Short-term, limited-duration health plans were originally intended to be a bridge when an individual had
a gap in comprehensive coverage – for instance when an individual was between jobs and temporarily
without access to an employer plan. Last year the Administration finalized a regulation that would
expand access to these products. Short-term plans traditionally have low premiums but fail to provide
the kind of comprehensive coverage an individual would need if they were diagnosed with a serious and
unplanned disease such as cancer. Issuers offering short-term plans are permitted to engage in medical
underwriting, meaning they can deny coverage to people with pre-existing conditions, can charge more
based on a person’s health status, or can refuse to cover services related to an individual’s pre-existing
conditions. They are also permitted to impose lifetime and annual limits on coverage and are not
required to provide coverage of the Affordable Care Act’s (ACA’s) essential health benefits.
To better understand whether short-term plans would be sold to cancer patients and, if so, what kind of
coverage a cancer patient could expect, we studied short-term plans in six states: Florida, Illinois,
Maine, Pennsylvania, Texas, and Wisconsin. We examined two zip codes within each of the six states to
better understand the extent to which premiums and deductibles varied between rural and urban areas.
Using a nationally-recognized online brokerage site, we created a hypothetical profile of an individual
57-year-old woman, non-smoker, looking for short-term, limited-duration plan availability in one urban
and one rural zip code in each of the six states. Our study assumed that the hypothetical woman would
be able to pass medical underwriting but then develop breast cancer once she was enrolled in the plan.
The goal was, in part, to understand how extensively a short-term plan might cover an unexpected and
costly condition that was not pre-existing and therefore not excluded outright. Some key findings are as
follows:
Pre-existing condition exclusions: We reviewed the brochures for each issuer examined in this white
paper and found that each one expressly stated that the plan excluded coverage for pre-existing
conditions. The final rule allowing for expansion of short-term plans requires this disclosure. Four of the
six brochures also included a “prudent layperson” standard within their definition of a pre-existing
condition. A prudent layperson standard includes undiagnosed conditions that produced symptoms
which would have caused a reasonably prudent person to seek diagnosis, care, or treatment. All
brochures said the issuer would consider as pre-existing only those conditions or symptoms that a
person experienced within a certain period of time prior to enrollment (i.e., two years or five years),
which is known as a lookback period. Depending on state law, some individuals can purchase back-to-
2. 2
back, or “stacked” policies. Five of the six brochures examined expressly noted that any conditions
developed while covered under a previous plan were considered pre-existing under the new plan.
Premium variation: Generally speaking, plan premiums were higher for products with longer coverage
periods, with the exception being the 36-month plans offered in Pennsylvania. In a majority of the states
examined, average plan premiums were less expensive in rural areas compared to urban areas. We also
examined the number of plans offered in each geographic area and found robust issuer participation in
most geographic areas.
Hypothetical Patient Profile: Short-term plans can be marketed as a protection against unexpected
illness or injury. Given that most cancer diagnoses are unexpected we endeavored to assess what kind
of coverage an individual who was diagnosed with breast cancer after enrolling in a short-term plan
could potentially be offered. We used the example of a 57-year-old, non-smoking woman as a
hypothetical patient profile. The scenario assumed she would pass medical underwriting and be able to
purchase a short-term plan but would then developed breast cancer after enrollment. To keep the
scenario simple, we assumed certain issuers would not raise premiums or rescind coverage for the
sample patient, even though individuals diagnosed with cancer and covered under a short-term plan
would likely face either higher premiums or cancellation of coverage.1
In our hypothetical, the total cost of treating breast cancer for the first year was estimated to be
$179,229.41, with health care costs highest in the month following diagnosis. We found the hypothetical
patient’s out-of-pocket costs would vary by duration of short-term plan as follows:
3-month plan: Assuming the enrollee was able to access all covered services in-network and
further assuming no delays in treatment, the plan would cover a little less than $60,000 in
services. The enrollee’s share of the treatment would amount to over $111,000, plus an
additional $363.90 in total premiums ($121.30 per month). The enrollee would become
ineligible for subsequent coverage of her cancer care in a short-term policy because her cancer
diagnosis would be considered a pre-existing condition.
6-month plan: Assuming the enrollee was able to access all covered services, the plan would
cover roughly $106,000 worth of the enrollee’s treatment. The enrollee would incur more than
$63,000 in cost-sharing related to her treatments, and an additional $1,570.56 in total
premiums ($261.76 per month).
12-month plan: The 12-month plan provided the most coverage relative to the other plans
examined. However, this plan still left the enrollee with over $40,000 in cost-sharing, not
including monthly premiums which totaled $31,184.52 ($2,598.78 per month). Taken together,
the enrollee’s cost-sharing and monthly premiums totaled $71,886.95, which is higher total
1
For example, people who are enrolled in short-term plans and then are treated for a serious illness may face
“post-claims underwriting,” in which the insurer examines their medical history and records for prior signs of the
condition, with the aim of deeming it pre-existing and avoiding payment of any related claims. Our scenario
assumed that did not happen to the enrollee. The scenario also assumed the insurer would pay the full in-network
charge of a given covered service, without any “balance billing,” which requires an enrollee to pay extra charges
not covered by the plan. For further details about the scenario used, see Appendix B.
3. 3
cost-sharing than that provided under a 6-month plan.
In all cases examined, the individual incurred significantly higher out-of-pocket costs under her short-
term plan than had she purchased a plan on the marketplace, which provides more robust coverage of
services (including prescription drug coverage) and imposes a yearly cap on in-network cost-sharing of
$7,900. In addition, because the expiration of short-term coverage is not considered a qualifying event,
the individual would be unlikely eligible to enroll in ACA-compliant coverage until the next ACA open
enrollment period.
Lack of availability and clarity of plan documents: We discovered that it can be difficult – if not
impossible – for consumers to assess what services a short-term plan covers and does not cover prior to
purchasing coverage. Indeed, most of the details about plan coverage were included in the plan’s policy
documents, which were not made available to individuals shopping for coverage. This was particularly
true with respect to plan coverage of prescription drugs. While not all plans offered drug coverage,
those that did failed to provide any formulary information. Short-term plans also appeared to provide
limited coverage for preventive services.2
Background
Having adequate and affordable health insurance coverage is a key determinant in surviving cancer.
Research from the American Cancer Society shows that uninsured Americans are less likely to get
screened for cancer and thus are more likely to have their cancer diagnosed at an advanced stage when
survival is less likely and the cost of care more expensive.3
This not only impacts the nearly 1.8 million
Americans who will be diagnosed with cancer this year, but also the 15.5 million Americans living today
who have a history of cancer.4
Short-term plans were originally intended to provide people who lacked health insurance coverage an
opportunity to obtain coverage as their name portends – for a brief period – before more
comprehensive coverage became available. These policies traditionally have low premiums but fail to
provide the kind of comprehensive coverage an individual undergoing active cancer treatment requires.
These plans were carved out from all federal health insurance laws, including the Affordable Care Act’s
2
For purposes of this study, we examined short-term plan issuers’ brochures to determine coverage of
prescription drugs, preventive services, and any other issues specifically related to cancer care. Other analysis has
shown that short-term plans also frequently do not provide coverage of maternity care or mental health and
substance use disorder. Pollitz K, Long M, Semanskee A, Kamal R. (2018, April 23). “Understanding short-term
limited duration health insurance.” Kaiser Family Foundation. Available at http://files.kff.org/attachment/Issue-
Brief-Understanding-Short-Term-Limited-Duration-Health-Insurance.
3
Ward E, Halpern M, Schrag N, Cokkinides V, DeSantis C, Bandi P, Stewart A, Jemal A. (2007). “Association of
Insurance with Cancer Care Utilization and Outcomes.” CA: A Cancer Journal for Clinicians 58(1), 9-31. Available at
http://www.cancer.org/cancer/news/report-links-health-insurance-status-with-cancer-care.
4
American Cancer Society. (2019). Cancer Facts & Figures 2019. Available at
https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-
figures/2019/cancer-facts-and-figures-2019.pdf.
4. 4
(ACA’s) patient protections, and thus are permitted to engage in medical underwriting, meaning issuers
can deny coverage to people with pre-existing conditions, can charge more for coverage, or can refuse
to cover services related to an individual’s pre-existing conditions. These plans are also permitted to
impose limits on coverage and are not required to provide coverage of the ACA’s essential health
benefits.5
Short-term plans are allowed to engage in post-claims underwriting, meaning that once a person is
enrolled in coverage if they submitted claims for an expensive service, the issuer would undertake an
investigation to determine whether the enrollee’s condition constituted a pre-existing condition. In
addition, short-term policies can and will end coverage at the policy’s term, even if the policyholder has
gotten sick and needs coverage to continue. Individuals whose coverage is rescinded or whose coverage
term ends are not generally eligible for a special enrollment period to enroll in comprehensive coverage
and thus are exposed to a gap in coverage.
In 2016, the Obama administration finalized a regulation that limited short-term plans to no more than
three months in duration (without the ability to extend coverage) and required such plans to display a
prominent disclaimer informing consumers that such coverage would not meet the ACA’s minimum
essential coverage requirements.6
In doing so, the Obama Administration cited concerns that short-term
plans were being sold as primary coverage and were adversely impacting the ACA risk pools.
In 2018, the Department of Health and Human Services (HHS), Department of Treasury, and the
Department of Labor (DOL) finalized a rule that changed the previous policy, allowing for expanded
access to short-term plans.7
Under the 2018 final rule, short-term plans were allowed to be sold for a
term of up to one year and be renewed, at the issuer’s discretion, for up to 36 months (without a
prohibition against the sale of back-to-back plans).
Some policymakers and advocates are concerned that the proliferation of short-term plans could
undermine the current insurance market by siphoning off younger, healthier individuals who would be
swayed by the lower premiums and would be more likely to pass medical underwriting compared to
older and sicker individuals. While older and sicker individuals could still seek coverage in the ACA-
compliant market, without younger and healthier individuals in the risk pool, the ACA-compliant market
would see premium increases to account for an older, sicker pool of enrollees. This effect is among the
5
The Affordable Care Act requires health plans to cover 10 Essential Health Benefits (EHBs): ambulatory patient
services; emergency services; hospitalizations; maternity care; mental health and substance use disorder services;
prescription drugs; laboratory services; habilitative and rehabilitative services; preventive and wellness services;
and pediatric oral and dental services.
6
Department of Health and Human Services, Department of the Treasury, and Department of Labor. Excepted
Benefits; Lifetime and Annual Limits; and Short-Term Limited-Duration Insurance. Final Rule. 81 Fed. Reg. 75316
(Oct. 31, 2016).
7
Department of Health and Human Services, Department of the Treasury, and Department of Labor. Short-Term,
Limited-Duration Insurance. Final Rule. 83 Fed. Reg. 38212 (Aug. 3, 2018).
5. 5
reasons why a coalition of patient advocates and safety net health insurers have challenged the new
final rule in court.8
The six states -- Florida, Illinois, Maine, Pennsylvania, Texas, and Wisconsin – and cities included in our
research were selected in order to provide for geographic diversity, varied overall size, and number of
expected cancer diagnoses in 2019. To date at least one state (Illinois) has enacted legislation to limit
the availability and duration of STLD policies.9
Pre-Existing Conditions
Prior to the enactment of the Affordable Care Act (ACA), individuals who had a history of cancer were
often unable to purchase health insurance coverage on the individual market because plans could refuse
to cover an individual who had a pre-existing condition (such as cancer), charge higher premiums to an
individual with a pre-existing condition, and/or choose to cover the person with a pre-existing condition
but not cover services related to the pre-existing condition. Pre-existing conditions often included
serious diseases such as cancer but could also apply to more common conditions such as acne.10
A survey conducted before these exclusions were prohibited in ACA-compliant plans found that 36 percent
of those who tried to purchase health insurance directly from an insurance company in the individual
insurance market were turned down, were charged more, or had a specific health problem excluded
from their coverage.11
The Kaiser Family Foundation estimates that 27 percent of adult Americans under
the age of 65 have a “declinable” pre-existing condition,12
with the prevalence of pre-existing conditions
increasing with age.
8
Litigation has been filed to halt the implementation of the short-term plan final rule. Association for Community
Affiliated Plans v. Treasury, No. 1:18-cv-02133 (D. D.C. filed Oct. 10, 2018). As of the date of this report that
litigation has not been resolved and is currently pending in the United States District Court for the District of
Columbia.
9
Goldberg, S. (2018, Nov. 28). “Illinois legislature overrides veto of short-term health plan limit.” Crain’s Chicago
Business. Available at https://www.chicagobusiness.com/health-care/illinois-legislature-overrides-veto-short-
term-health-plan-limit.
10
Schwab, R. (2016, Dec. 7). “From Acne to EcZema: The Return of Medical Underwriting Puts Millions at Risk for
Losing Coverage or Higher Premiums.” Georgetown University Health Policy Institute Center on Health Insurance
Reforms. Available at http://chirblog.org/from-acne-to-eczema-the-return-of-medical-underwriting-puts-millions-
at-risk-for-losing-coverage-or-higher-premiums/.
11
Doty M. M, Collins S. R, Nicholson J. L, and Rustgi S. D. (2009, July). “Failure to Protect: Why the Individual
Insurance Market is not a Viable Option for Most US Families.” Commonwealth Fund. Available at
https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_issue_brief_20
09_jul_failure_to_protect_1300_doty_failure_to_protect_individual_ins_market_ib_v2.pdf.
12
Claxton G, Cox C, Damico A, Levitt L, Pollitz K. (2016, Dec.). “Pre-existing Conditions and Medical Underwriting in
the Individual Insurance Market Prior to the ACA.” Kaiser Family Foundation. Available at
http://files.kff.org/attachment/Issue-Brief-Pre-existing-Conditions-and-Medical-Underwriting-in-the-Individual-
Insurance-Market-Prior-to-the-ACA.
6. 6
Because short-term plans are exempt from the ACA’s consumer protections, they are permitted to deny
coverage to individuals with pre-existing conditions. A summary of our analysis of issuer brochures is
reflected in Table 1, below:
Table 1: Pre-Existing Condition Exclusions by Issuer13
Issuer A Issuer B Issuer C Issuer D Issuer E Issuer F
Defined term No Yes Yes Yes Yes Yes
Includes prudent
layperson
standard
No Yes Yes Yes Yes No
Lookback period 60 months 60 months 12 months 60
months
24 months for
treatment
received;
12-month prudent
layperson
None listed
Pre-existing
condition
protections
extending to back-
to-back policies
No new
medical
questions
or waiting
periods for
stacked
coverage
Subsequent
policies are
subject to
new pre-
existing
condition
limitations
Subsequent
policies
only cover
conditions
covered
under a
previous
plan within
90 days
Unclear Subsequent
policies are subject
to new pre-
existing condition
limitations
Subsequent
policies are
subject to
new pre-
existing
condition
limitations
Based on author review of issuer brochures. In examining plan availability in the six states, we found six distinct issuers offering
coverage options.
* Issuer A’s brochure also noted that enrollees who purchased stacked policies would not be subject to additional medical
questions or new waiting periods.
“Pre-existing condition” definition: In reviewing the brochures for each issuer examined in this white
paper, we found that every issuer’s plan brochure expressly stated that coverage for pre-existing
conditions were excluded from coverage under the plan. All but one of the brochures we examined
defined the term “pre-existing condition,” though the definitions varied slightly.
13
Issuers are not identified by name because this paper includes a small illustrative sample of short-term plans;
and was not a comprehensive examination of all issuers in a state. Additionally, the report is not intended to
provide information about particular plans to consumers, but to discuss trends in the market.
7. 7
Some of the issuer brochures we examined were intended for products sold in multiple states, and thus
contained state-specific terms that varied slightly from the general term used in the brochure.14
Where
state variation existed it usually concerned the period under which an issuer could engage in post-claims
underwriting. One issuer’s brochure noted that the plan did not cover pre-existing conditions including
those not inquired about on the enrollment form. None of the brochures listed specific diseases or
conditions that would constitute a pre-existing condition for which the applicant would be denied
coverage.
“Prudent layperson” standard: Four of the six brochures also included a “prudent layperson” standard –
meaning that the issuer considers a pre-existing condition to be something that produced symptoms
which would have caused a reasonably prudent person to seek diagnosis, care, or treatment. The
“prudent layperson” standard provides issuers with additional flexibility to deny coverage to
applicants – or rescind coverage from individuals after they enroll. For example, after enrolling in a
short-term plan an individual is diagnosed with brain cancer. If upon investigation the issuer discovers
the individual experienced headaches prior to enrolling in the plan, the issuer may determine the brain
cancer is a pre-existing condition because a prudent layperson would have sought medical advice to
address their headaches and thus refuses to pay for the individual’s brain cancer treatments.
Lookback period: All issuer brochures examined noted they would employ a lookback period, which is a
limit on the amount of time, prior to enrollment, the issuer will look at a person’s medical history for
evidence of a pre-existing condition that warrants a denial of a person’s application or nonpayment of
the person’s claims related to the condition. The length of the lookback period varied by issuer. Five out
of the six brochures specifically noted the length of the look-back period.
Back-to-back policies: Depending on state law, short-term plans can now be “stacked”, meaning that an
individual could purchase back-to-back plans, thereby extending the period of time during which one is
enrolled in a short-term plan. Plan stacking is often confusing to consumers, who frequently assume that
issuers will not medically underwrite as long as the individual retains continuous coverage with the same
issuer. However, five of the issuers’ brochures expressly noted that any pre-existing conditions
developed while covered under a previous plan are considered pre-existing under the new plan. Thus, if
an individual developed a disease or condition while enrolled in a short-term plan offered by these
issuers, she would be unable to purchase another short-term plan because of the ability of plans to deny
coverage to individuals with pre-existing conditions. Because the expiration of short-term coverage is
not considered a qualifying event, the individual would be unlikely eligible to enroll in other coverage,
likely leaving her uninsured until the next open enrollment period.
The sixth issuer specifically highlighted the benefits of stacked plans by noting that while the cost-
sharing responsibilities would restart with a new plan, any medical conditions that arose while covered
under the initial short-term plan would be covered under the subsequent policy. But the brochure also
said these features were subject to plan limitations as noted in policy documents (which were
14
This could be confusing to consumers who would not only have to find information related to policy exclusions
among the general exclusions but would also have to look elsewhere in the document to determine if additional
exclusions or changes to the brochure were in effect depending on the state in which the applicant resides.
8. 8
unavailable). On its face this statement suggests the issuer is providing an important consumer
protection. However, short-term plans can engage in post-claims underwriting, which would allow the
issuer to rescind coverage.
Premiums and Deductibles
Short-term plans typically have lower premiums relative to ACA-compliant health plans (particularly
unsubsidized ACA plans) because short-term plans are not required to provide comprehensive benefits
and can exclude individuals with pre-existing conditions or avoid covering their claims. We examined
two zip codes within each of the six study states to better understand the extent to which there was
premium variation. Health insurance premiums vary for a variety of reasons including, among other
things, the value of the benefits covered, health status of the enrollee, and geography. We were unable
to ascertain the actuarial value of covered benefits and the premiums listed do not account for any
medical underwriting.15
The summary of our analysis is reflected in Table 2, below:
Table 2: Average Monthly Premiums for 57-Year-Old Woman in Chosen Zip Code by State
City State Urban/Rural 3-month 6-month 12-month 36-month
Chicago (60639) IL Urban $349.29 $498.16
LaSalle (61301) IL Rural $271.22 $384.80
Houston (77051) TX Urban $492.84 $666.70
Mission (78572) TX Rural $473.23 $646.61
Allagash (04774) ME Rural $266.15 $393.86
Portland (04103) ME Urban $266.15 $393.86
Jackson (32446) FL Rural $311.26 $403.93
Miami-Dade (33172) FL Urban $393.33 $506.18
Milwaukee (53202) WI Urban $312.93 $398.65
Waupaca (54981) WI Rural $272.38 $385.48
Pittsburgh (15286) PA Urban $290.48 $416.35 $576.75 $386.34
Towanda (18848) PA Rural $289.74 $393.79 $545.16 $344.65
Source: Analysis of premium provided by online broker. Averages include median premium across all issuers. Premiums do not
reflect medical underwriting, meaning actual premiums could be higher than shown here.
The 3-month and 36-month plan options were only available in Pennsylvania.
Coverage length: In only one state – Pennsylvania – 3-month and 36-month plans were available.16
In all
of the states that we examined, 6-month and 12-month plans were available. Generally speaking, plan
premiums were higher for products with longer coverage periods. One notable exception was that
average plan premiums for the 36-month plans were less than premiums for 12-month plans. Average
15
In general, it was challenging to determine specific information regarding plan coverage and benefits, as
discussed further in the “Consumer Disclosure Material” section of this paper.
16
This could be due to the fact that the data for plan availability in Pennsylvania was gathered in March 2019,
rather than November 2018 when the information for the other states was gathered.
9. 9
monthly premiums for 36-month plans in Pittsburgh, Pennsylvania were $190.41 less than the average
monthly premium for the 12-month plan and $30.01 less than the average monthly premiums for the 6-
month plan. Similarly, in Towanda, Pennsylvania average premiums for 36-month plans were $200.51
less than average premiums for 12-month plans and $49.14 less for 6-month plans.
Urban versus rural: In a majority of the states examined, premiums were on average less expensive in
rural areas compared to urban areas. The notable exception involved products offered in Maine which
had the same average premium for both urban and rural areas. Illinois and Florida saw the greatest
variation in average premiums between rural and urban areas.
In addition to analyzing the premiums of short-term health plans, we also examined the use of the
deductibles for these plans. Short-term plans, like most health insurance coverage, utilize a benefit
design that includes a deductible.17
The summary of our analysis is reflected in Table 3, below:
Table 3: Most Common Deductibles by State
City State Urban v Rural 3-Month 6-Month 12-Month 36-Month
Chicago (60639) IL Urban $5,000 $5,000
LaSalle (61301) IL Rural $5,000 $5,000
Houston (77051) TX Urban $5,000 $5,000
Mission (78572) TX Rural $5,000 $5,000
Allagash (04774) ME Rural $10,000 $10,000
Portland (04103) ME Urban $2,500 $2,500
Jackson (32446) FL Rural $5,000 $5,000
Miami-Dade (33172) FL Urban $5,000 $5,000
Milwaukee (53202) WI Urban $5,000 $5,000
Waupaca (54981) WI Rural $10,000 $5,000
Pittsburgh (15286) PA Urban $10,000 $10,000 $5,000 N/A
Towanda (18848) PA Rural $10,000 $5,000 $5,000 N/A
Source: Analysis of deductibles provided by online broker.
Some plans use a separate prescription drug deductible, to the extent they provided any drug coverage, which is not reflected
in the above data.
The 3-month and 36-month plan options were only available in Pennsylvania. Plan deductibles varied so significantly for the 36-
month plan options that it was not possible to ascertain the most commonly utilized deductible.
Deductibles: Every state examined offered 6-month and 12-month plan options, and the most widely
used deductible for both options was $5,000 – meaning that the enrollee would have to spend $5,000
before the plan began covering services. The most common deductible for the plans examined in
Allagash, Maine was the only area examined with an average deductible of $10,000 for both the 6-
month and 12-month plan options.
17
A deductible is the amount an individual pays out of pocket before their health plan starts to cover services.
10. 10
Individuals who purchased back-to-back policies would have deductible obligations for each new period
of coverage. In other words, an individual who purchased four consecutive 3-month plans, would have
to meet a new deductible every three months before the plan would begin to cover services.
Plan deductibles varied widely, with every state having plans available with a deductible as low as
$1,000. In every state but Maine, plan deductibles were as high as $12,500. Plan deductibles in Maine
ranged from $1,000 to $10,000. As a point of comparison, plans sold on the ACA marketplace are
required to cap total annual out-of-pocket costs for in-network services at $7,900 and provide more
robust coverage (including prescription drug coverage).
Finally, we noted that plan availability was relatively robust in each geographic area we examined. The
summary of our analysis is included in Table 4, below:
Table 4: Plan Options and Number of Issuers by State
City
State 3-Month 6-Month 12-Month 36-Month
Number of
Issuers
Chicago (60639) IL 42 45 5
LaSalle (61301) IL 42 45 5
Houston (77051) TX 42 50 5
Mission (78572) TX 42 50 5
Allagash (04774) ME 16 16 1
Portland (04103) ME 16 16 1
Jackson (32446) FL 42 50 5
Miami-Dade (33172) FL 42 50 5
Milwaukee (53202) WI 36 46 4
Waupaca (54981) WI 41 44 4
Pittsburgh (15286) PA 26 19 20 4 5
Towanda (18848) PA 26 19 20 4 5
Source: Analysis of information provided by online broker.
Plan options: Every state we examined had robust issuer participation, with the two geographic areas in
Maine (Allagash and Portland) having the fewest plan options – only 16 plan choices for both the 6-
month and 12-month plan options. The two geographic areas in Texas (Houston and Mission) offered
the most robust plan choices with a total of 92 plan options (between both the 6-month and 12-month
plans) in each of the geographic areas.
As discussed in more detail in the Consumer Disclosure section below, consumers shopping for coverage
were provided with basic information about the plan (premium, deductible, coinsurance), but we were
not able to ascertain the actuarial value of the covered benefits. Thus, it would be challenging for a
consumer to make an informed decision when choosing a plan.
Issuer participation: None of the geographic areas examined provided plan options from all six issuers
examined in this report. Most geographic areas – those in Illinois, Texas, Florida, and Pennsylvania –
11. 11
included plan options from five out of the six issuers examined in the report. Maine was the only state
examined that only had one issuer.
Interestingly, in four of the six states examined, one issuer appeared to offer mirror plans. For example,
in looking at the index of plan choices in Jackson, Florida this issuer offered a 12-month plan with a
monthly premium of $329.41, a $10,000 deductible, and 20 percent co-insurance on covered services. In
the index of plans, the immediately subsequent plan offering was an identical plan, with the same
coverage period, premium, deductible, and cost-sharing. Since this issuer used a standard brochure
across all plans, it was impossible to ascertain what, if any, difference existed between these two plan
offerings. This duplication of plans appeared in more than one geographic area and often several times
per area, which suggested it was a conscious decision by the issuer rather than an error on the part of
the online brokerage site.
Cancer Care Illustrative Examples
Short-term plans are not subject to the patient protections provided under the ACA. As noted, they do
not have to offer coverage of essential health benefits and these plans can deny coverage to individuals
with pre-existing conditions. Most individuals with cancer (or a personal or family history of cancer)
would likely be denied coverage altogether due to the medical underwriting practice employed by these
issuers. For those able to pass medical underwriting and enroll in a short-term plan, cancer would likely
be treated as a pre-existing condition, and coverage for cancer treatment would be excluded under the
policy.
Some cancer patients are diagnosed with cancer after having no prior medical history or symptoms –
and therefore it is possible an individual could pass medical underwriting, be enrolled in a short-term
plan, and then be diagnosed with cancer. However, short-term plans have been known to rescind
coverage, claiming the enrollee had a pre-existing condition that was not adequately disclosed, when
faced with a large claim, such as those associated with cancer care.18
We wanted to determine what coverage potentially could be provided to a woman who was diagnosed
with breast cancer after enrolling in a short-term plan, setting aside the other problems with short-term
plans that such a person would likely face in real-life. In 2017, the American Cancer Society Cancer
Action Network released The Cost of Cancer, a report focusing specifically on the costs of cancer borne
by patients in active treatment as well as survivors.19
To more fully illustrate what cancer patients
actually pay for care the Cost of Cancer report also presents scenario models for a breast cancer patient.
For the purposes of this report, we used cost and utilization information from the Cost of Cancer
18
Levey, N. N. (2019, April 2). “Skimpy health plans touted by Trump bring back familiar woes for consumers.” LA
Times. Available at https://www.latimes.com/politics/la-na-pol-trump-shortterm-health-insurance-consumer-
problems-20190402-story.html.
19
American Cancer Society Cancer Action Network. (2017, April). The Costs of Cancer: Addressing Patient Costs.
Available at www.fightcancer.org/costsofcancer.
12. 12
report,20
and for purposes of the illustration assumed the plan covered all services unless otherwise
expressly noted in the plan brochures.
3-Month Plan
Three-month policies were only available in one of the states examined (Pennsylvania). Noting that
consumers often chose a health plan based on the premium offered, we chose to examine a three-
month plan with the lowest premium offered in Pittsburgh, Pennsylvania.21
For this analysis, we assume
a new enrollee who was diagnosed with breast cancer at the beginning of the policy would not have her
policy rescinded.
This policy offered coverage for a 57-year old, non-smoking woman as follows:
Monthly Premium Deductible Coinsurance Out-of-Pocket Limit
$121.30 $12,500 30% $22,500
This particular plan operated an Exclusive Provider Organization (EPO) network, which required the
enrollee to use only in-network providers. For purposes of our analysis we assumed all providers were
in-network. The brochure noted that policies issued in Pennsylvania would require coverage of one
routine mammogram for individuals over 40 years of age.
For purposes of the illustration, total annual costs for a 57-year old woman with breast cancer were
estimated to be $170,229.41.22,23
The costs of cancer care are highest following diagnosis. The main
sources of costs for the enrollee’s treatment during the first three months were physician services,
imaging, and surgery.24
The 3-month plan offered by this issuer did not cover outpatient prescription
drugs, though it did offer a discount card. The scenario does not call for the enrollee to incur any
outpatient prescription drug costs within the first three months of treatment.
Assuming that the enrollee was able to access all services in-network and further assuming no delays in
treatment, the plan would cover a little less than $60,000 in services during the three months this
individual had coverage. She would then become ineligible for coverage for her cancer care in a
subsequent short-term policy because her cancer diagnosis would be considered a pre-existing
condition. The enrollee’s share of the treatment for the year would amount to over $111,000 –
excluding premiums (which would total $363.90 for the three months of coverage). This would be
20
More information on services contained in the Cost of Cancer report is available in Appendix B.
21
As noted earlier, short-term plan premiums available for this analysis do not reflect medical underwriting,
meaning that actual premiums may be higher.
22
For purposes of this illustration, the “costs” referred to estimated costs for services used for ACS CAN’s Cost of
Cancer report. More information is available at Appendix B.
23
Unless otherwise stated, the term “costs” refers to total annual costs.
24
For purposes of this illustration it is assumed that surgical procedures would include prescription drugs, which
would be covered as part of the bundled payment for the surgical procedure. It is not possible from publicly
available documents to determine whether surgical procedures would be billed as a bundled payment.
13. 13
unaffordable for most Americans.
Nearly half of all American adults
report being unable to cover an
emergency expense costing $400
without having to borrow or sell
something to do so.25
In the first month of coverage the
plan paid less than $200, leaving the
enrollee to pay more than $8,000,
which was still less than her $12,500
deductible. This 3-month plan
covered only 35 percent of the
enrollee’s costs, mostly due to the
fact that the plan did not provide any
services beyond the first three
months.
After three months the enrollee could not obtain coverage for her cancer treatment from the same
issuer. The issuer’s brochure said it will not cover benefits for a health condition discovered under a
prior plan. Because the end of the three months of short-term coverage is not considered a qualifying
event, the person would unlikely be eligible to enroll in ACA-compliant coverage, likely leaving her
uninsured—while in active cancer treatment—until the next ACA open enrollment period.
As a point of comparison, if the individual enrolled in an ACA plan, her plan would provide coverage for
benefits not covered by the short-term plan (such as prescription drugs). The ACA plan would be
required to cap her in-network cost sharing each year at $7,900.
3-month plan
ACA Plan
Annual Limit
Savings by
choosing an
ACA Plan
Total out-of-pocket costs
(excluding premiums)
$111,128.43 $7,900 $103,228.43
The phrase “ACA plan annual limit” refers to the Affordable Care Act’s annual limit total out-of-pocket expenses an enrollee
would incur for in-network covered services.
25
Board of Governors of the Federal Reserve. (2016, May). Report on the Economic Well-Being of U.S. Households
in 2015. Available at https://www.federalreserve.gov/2015-report-economic-well-being-us-households-
201605.pdf.
$59,100.98
$111,128.43
$363.90
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Plan and Enrollee Cost-Sharing
3-Month Plan
Plan Pays Enrollee OOP costs Enrollee premiums
14. 14
6-Month Plan
We chose to examine a 6-month plan in Florida given that the state has the highest incidence of breast
cancer (among the states examined in this report).26
The online brokerage site we used gave consumers
several options in which to sort plans. We chose the first 6-month plan that appeared in the
“recommended” sorting option (which is also the default option) offered in Miami-Dade, Florida.
This policy offered coverage for a 57-year old, non-smoking woman as follows:
Monthly Premium Deductible Coinsurance Out-of-Pocket Limit
$261.76 $10,000 20% $20,000
This product was an indemnity product, meaning there was no plan network available and that
consumers are responsible for seeking reimbursement directly from the health plan (rather than having
the provider submit claims). More importantly, indemnity plans can expose consumers to additional
costs because the plan will provide limited reimbursement based on a set formula, regardless of the
actual amount billed. In many situations this means the patient’s doctor will bill the patient for the
amount the insurer did not pay (called balance billing).27
Because we could not quantify the amount of
any balance billed services, for purposes of this illustration we assumed the enrollee would not incur any
additional costs as a result, even though in reality she probably would.
The issuer’s brochure specifically noted that enrollees would not be entitled to receive any benefits for
cancer during the first 30-days of coverage (it was the only issuer examined that had a 30-day waiting
period for cancer-related services). The enrollee incurred over $8,000 in costs in the first month.
The issuer offers consumers the choice of back-to-back policies (e.g., stacked policies), as long as they
are purchased together. According to the brochure, any medical conditions that may arise under the
initial policy would be covered under new certificates, subject to plan limitations (including a higher
premium). For purposes of this illustration we assumed the consumer chose to purchase one 6-month
policy and at the time of purchasing her initial coverage did not purchase a second (stacked) 6-month
policy. As with the example under the 3-month plan, she may not qualify for a special enrollment period
to enroll in ACA coverage until the next open enrollment period, leaving her potentially uninsured until
that time.
26
In 2019, the estimated number of new cases of female breast cancer among the states examined in this report
are as follows: Florida (19,130), Illinois (11,560), Maine (1,390), Pennsylvania (12,070), Texas (18,750) and
Wisconsin (5,270). American Cancer Society. (2019). Cancer Facts & Figures 2019. 5. Available at
https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-
figures/2019/cancer-facts-and-figures-2019.pdf.
27
Short-term plans that do not use a provider network increase the risk of enrollees being faces with significant
balance billing charges. Goe, C. L. (2019, April 30). “Short-term plans: no provider networks lead to large bills for
consumers.” Commonwealth Fund. Available at https://www.commonwealthfund.org/blog/2019/short-term-
plans-large-bills-consumers.
15. 15
For purposes of the illustration, total annual
estimated costs for a 57-year old woman with
breast cancer were $170,229.41. Assuming
that the enrollee was able to access all
services without being subject to balance
billing, the plan would cover roughly
$107,000 of the enrollee’s yearly treatment.
The enrollee would incur more than $63,000
in cost-sharing related to her treatments, and
an additional $1,570.56 in premiums.
While the 6-month plan would cover more of
the enrollee’s expected costs than the 3-
month plan discussed above, it is important
to note that even under this scenario, the
enrollee would still be responsible for cost-sharing (including premiums) of approximately $65,000 – a
cost well out of the reach of most Americans.
As a point of comparison, if the individual enrolled in an ACA plan, her plan would provide coverage for
benefits not covered by the short-term plan (such as prescription drugs). The ACA plan would be
required to cap her in-network cost sharing each year at $7,900.
6-month plan
ACA Plan
Annual Limit
Savings by
choosing an
ACA Plan
Total out-of-pocket costs
(excluding premiums)
$63,019.26 $7,900 $55,119.26
The phrase “ACA plan annual limit” refers to the Affordable Care Act’s annual limit total out-of-pocket expenses an enrollee
would incur for in-network covered services.
12-Month Plan
We chose a 12-month plan offered in Houston, Texas because this plan required the highest premium
($2,598.78 per month) among all 12 areas examined. We wanted to ascertain whether purchasing a plan
with a higher premium provided an enrollee with more robust coverage.
This policy offered coverage for a 57-year old, non-smoking woman as follows:
Monthly Premium Deductible Coinsurance Out-of-Pocket Limit
$2,598.78 $1,000 50% $6,000
This plan also had features of an indemnity plan which exposes enrollees to additional cost-sharing for
balance billing which was not quantifiable for purposes of this analysis. This policy stated that enrollees
would incur a $50 copayment for physician services (for both primary care and specialists), though the
$106,709.35
$63,019.26
$1,570.56
0%
20%
40%
60%
80%
100%
Plan and Enrollee Cost-Sharing
6-Month Plan
Plan Pays Enrollee OOP costs Enrollee premiums
16. 16
brochure indicated subsequent visits would be subject to the plan deductible and coinsurance, without
specifically defining a coinsurance related to physician services. Given the relatively low out-of-pocket
limit, under the illustration the enrollee would have only had one physician visit before hitting the cap.
While this policy had a lower out-of-pocket cap
compared to other short-term plans examined, the
brochure noted that the cap did not include the
deductible. Also, while the premiums were significant,
the plan only covered prescription drugs when
prescribed on an inpatient basis for a covered disease
or sickness. The plan did, however, indicate that it
offered an outpatient prescription drug discount
program, though provided no information regarding
the program or its formulary.
Of the three plans examined, the 12-month plan
provided the most coverage.28
However, this plan still
left the enrollee with over $40,000 in cost-sharing, not
including monthly premiums which totaled $31,184.52
over the 12-month period. Taken together, the enrollee’s cost-sharing and monthly premiums totaled
$71,886.95, which is actually higher than what the illustrative patient would pay under a 6-month plan
scenario.
As a point of comparison, if the individual enrolled in an ACA plan, her plan would provide coverage for
benefits not covered by the short-term plan (such as prescription drugs). The ACA plan would be
required to cap her in-network cost sharing each year at $7,900.
12-month plan
ACA Plan
Annual Limit
Savings by
choosing an
ACA Plan
Total out-of-pocket costs
(excluding premiums)
$40,702.43 $7,900 $32,802.43
The phrase “ACA plan annual limit” refers to the Affordable Care Act’s annual limit total out-of-pocket expenses an enrollee
would incur for in-network covered services.
28
This statement is predicated on the assumption that the 12-month plan provided robust coverage of physician
services. The authors are unable to verify this claim given the lack of transparency regarding the plan’s coverage of
services.
$129,526.9
8
$40,702.43
$31,184.52
0%
20%
40%
60%
80%
100%
Plan and Enrollee Cost-Sharing
12-Month Plan
Plan Pays Enrollee OOP costs Enrollee premiums
17. 17
Consumer Disclosure Materials
In order to assess coverage options, consumers need information regarding what the policy does and
does not cover, as well as any expected cost-sharing for covered services. Insurance concepts can be
challenging for consumers to understand, and thus any information intended for consumers should be
presented in a clear and concise manner so consumers can assess their coverage options and make an
apples-to-apples comparison. One recent study suggests that consumers are confused by the limitations
of short-term plans because they have been shaped by their experiences and expectations of the
insurance market since the enactment of the ACA and expect all insurance coverage to contain
important patient protections.29
Lack of Summary of Benefits and Coverage: Under the ACA, plans – including grandfathered plans30
– are
required to provide enrollees (and potential enrollees) with a Summary of Benefits and Coverage (SBC)
that provides an easy-to understand, standardized summary of the benefits provided under the plan,
including prescription drug formulary information.31
Short-term plans do not have to comply with this requirement, which makes it harder for consumers to
assess materials that describe what services are, and are not, covered under the plan prior to purchasing
coverage. Indeed, most of the details about plan coverage were said to be included in the plan’s policy
documents, which were not made available to individuals shopping for coverage.
Lack of formulary information: Qualified Health Plans (QHPs) – ACA-compliant plans in the individual
and small group markets – are required to provide consumers with prescription drug coverage as well as
information regarding a plan’s prescription drug formulary (i.e., list of covered drugs). Three of the
issuers examined in this report did not provide any coverage of outpatient prescription drugs. One issuer
noted under its excluded benefits page that outpatient prescription drugs were not covered unless
shown as included in the Schedule of Benefits, which was not available to consumers shopping for
coverage.
Another issuer provided prescription drug coverage for some plan options but not for others. While the
brochure supplied by the issuer noted that outpatient prescription drugs would be subject to a separate
prescription drug deductible, it did not provide access to any formulary information. However, the
brochure noted that no specialty drugs were covered under any plan offered by the issuer. Many cancer
drugs are considered specialty drugs.32
29
Consumer Representatives to the National Association of Insurance Commissioners. (2019, Mar. 15). New
Consumer Testing Shows Limited Consumer Understanding of Short-Term Plans and Need for Continued State and
NAIC Action. Available https://healthyfuturega.org/wp-content/uploads/2019/04/Consumer-Testing-Report_NAIC-
Consumer-Reps.pdf.
30
A “grandfathered health plan” is a policy that was purchased before March 23, 2010. These plans are exempt
from many of the protections provided under the Affordable Care Act.
31
45 C.F.R. § 147.200.
32
Most cancer drugs (such as chemotherapy) are considered specialty drugs because they often require special
handling, administration, and/or monitoring. Depending on the insurer and the type of chemotherapy, these drugs
can be covered under a plan’s medical benefit, not the plan’s prescription drug benefit.
18. 18
Finally, another provided confusing information regarding prescription drug coverage. The brochure
seemed to indicate that one out of the four plan options does not cover prescription drugs – offering
only a discount card. The remaining three plan options seemed to indicate the plan provided some drug
coverage, though the brochure did not mention any formulary information. Consumers were told to pay
for their prescriptions at the point of sale “at the lowest price available” and to then submit a claim to
the plan for reimbursement. Even then, the brochure indicated that the issuer imposed a maximum
$3,000 benefit for prescription drugs. However, in the exclusions section of the brochure, the issuer
explicitly stated, “no benefits are payable for expenses … for outpatient prescription drugs, except as
provided for in the policy/certificate.” Neither the policy nor the certificate was made available to
individuals shopping for coverage.
Disclaimer: All of the examined issuer brochures included a disclaimer of some kind. These disclaimers
all noted that the coverage provided does not qualify as minimum essential coverage as required under
the Affordable Care Act. Four issuers’ disclaimers noted that not having minimum essential coverage
could result in a federal tax penalty.
One issuer included a disclaimer noting that short-term plan coverage does not constitute minimum
essential coverage, followed by a statement that the plan “can, however, offer financial protection in
the event of an unexpected injury or illness when you are waiting for coverage to begin under an ACA-
compliant plan.” Most cancer diagnoses are unexpected. The disclaimer offered by this issuer implies
that the policy would provide coverage for an unexpected illness, yet as our analysis demonstrated, the
coverage proved inadequate with respect to a diagnosis of breast cancer. The 12-month plan discussed
in detail above, offered by this issuer would leave a patient with over $40,000 in out-of-pocket costs
(excluding premiums).
Preventive Services
Cancers that are found at an early stage through screening are less expensive to treat and lead to
greater survival.33
Providing access to high quality primary medical care and preventive services is one of
the most effective ways to prevent or detect cancer at an earlier, more curable, and less expensive
stage. ACA-compliant plans are required to cover without cost-sharing clinical preventive services that
receive an “A” or a “B” rating from the United States Preventive Services Task Force (USPSTF) as well as
vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). These services
include breast, cervical colorectal, and lung cancer screenings, tobacco cessation treatment, weight loss
interventions to reduce obesity, and a vaccine that prevents cervical and other cancers.
Cancer screenings: It was very hard to ascertain whether the issuers covered routine cancer screenings
of any kind. Only two issuers noted in their plan brochures that they offered coverage for any cancer
screenings. Neither of these issuers offered coverage for all the cancer screenings recommended by the
USPSTF. Of the two issuers who provided any cancer screening coverage, one issuer’s brochure notes
33
American Cancer Society. (2017). Cancer Prevention & Early Detection Facts & Figures 2016-2017.
19. 19
that it covers mammography, pap smear, and prostate antigen test, though did not provide additional
information regarding the intervals at which these services would be covered34
and whether any cost-
sharing would be imposed. The other issuer’s brochure noted that it covered colorectal cancer screening
examinations, prostate specific antigen testing, and any preventive services required by the state.35
Tobacco cessation products: Quitting tobacco use can often require multiple quit attempts and
treatment is more likely to be successful with the use of scientifically-effective treatments including
prescription medications. Four of the six issuer brochures explicitly note they do not provide coverage
for tobacco cessation products. While the remaining two issuer brochures did not specifically mention
coverage for tobacco cessation products, neither of these issuers provide coverage for out-patient
prescription drugs.
Wellness exams: Short-term plans are not required to cover physical exams. In reviewing plan
brochures, only one issuer explicitly noted that “wellness exams” were covered for a $50 copayment.
However, with respect to the other issuers there were inconsistencies between the information
provided in the plan brochures and the information available in the “details” page displayed by the
online broker. For example, another issuer’s brochure exclusions and limitations section expressly states
that it does not cover costs for routine physical exams or other services not needed for medical
treatment, but the “details” page provided by the online broker states that preventive health exams are
covered on a limited basis.
34
The USPSTF screening recommendations provide specific screening intervals. For example, the USPSTF
recommends screening for cervical cancer in women age 21 to 65 every three years. U.S. Preventive Services Task
Force. Cervical Cancer: Screening. Release date Aug. 2018.
35
This issuer used a multi-state brochure which made it confusing for consumers to gain a better understanding of
what is covered under a specific plan option.
20. 20
ACS CAN Recommendations
Proponents of short-term plans often claim these products are not intended for all consumers but
rather offer a more affordable option than the robust ACA marketplace plans. While premiums for
short-term plans are generally lower relative to ACA plans, our analysis shows that short-term plans
actually expose enrollees with serious illnesses to higher out-of-pocket cost. These costs can be tens of
thousands of dollars which is far beyond the financial means of most Americans.
Research suggests that consumers generally do not understand short-term plans’ limitation on covered
benefits,36
particularly given that they have become accustomed to, and now expect the patient
protections provided under the ACA (such as the prohibition of medical underwriting). Some of this
confusion may be due to how these plans are marketed. As noted earlier, one issuer’s disclaimer
specifically noted that the product was intended to offer financial protection for an unexpected illness.
Yet our analysis showed the short-term plans included in this report exposed the enrollee to significant
out-of-pocket costs associated with an unexpected diagnosis of breast cancer.
We also note that the short-term plans examined in this report failed to provide information necessary
to determine an enrollee’s out-of-pocket costs and coverage of benefits related to an individual’s cancer
treatment. For example, we were not able to ascertain the exact premiums an individual would pay if
she enrolled in a short-term plan because the premiums made available to those shopping for coverage
did not reflect medical underwriting.
Short-term plans are allowed to deny coverage based on an individual’s pre-existing conditions – in
many cases whether or not those pre-existing conditions were known at the time coverage was sought.
This allows short-term plans to discriminate against individuals with high health care costs.
Even if an individual were able to pass medical underwriting and obtain coverage under a short-term
plan, the plans examined in this report failed to provide sufficient coverage for the products and services
cancer patients need for their treatment. Indeed, many of the short-term plans failed to provide
comprehensive access to preventive services, which are key to diagnosing cancer at an earlier stage
when an individual has a greater likelihood of a successful outcome. Half of the short-term plans
examined in this report did not provide any coverage of outpatient prescription drugs. Of the plans that
indicated there was some prescription drug coverage, none of the plans provided information on the
plan’s formulary. The issuers’ brochures would often refer to a Schedule of Benefits or other policy
documents, which were not provided to individuals shopping for coverage.
Short-term plans also have a negative impact on the risk pool for ACA-compliant plans. Short-term plans
tend to attract younger, healthier individuals who are lured by the plans’ lower premiums and more
likely to be approved for coverage given their health status. As a result, older and sicker individuals are
left in the ACA-compliant plan risk pool, which results in increased premiums for those plans. As
36
Consumer Representatives to the National Association of Insurance Commissioners. New Consumer Testing
Shows Limited Consumer Understanding of Short-Term Plans and Need for Continued State and NAIC Action.
21. 21
premiums become more expensive, individuals, particularly those who do not qualify for subsidies, are
more likely to forego coverage due to cost.
Policymakers should consider prohibiting the sale, or at the very least limiting the availability of short-
term plans because of the inadequacy of their coverage, combined with the negative impact on the risk
pool and availability of coverage in the ACA-compliant market. Since the Administration’s final rule
which expanded access to short-term plans went into effect, there has been a significant increase in the
length of coverage for short-term plan options, which can be confusing to consumers who may mistake
these plans for comprehensive, ACA-compliant coverage.
While the federal government finalized a rule expanding access to these plans, there are a number of
states that have taken action to address the concerns raised by the proliferation of short-term plans.37
Some states have enacted policies that prohibit short-term plans from engaging in medical underwriting,
and other states have enacted limits on the length of time a consumer could be enrolled in a short-term
plan.38
Action taken by states to strengthen their markets should be encouraged but ultimately result in
a patchwork of consumer protections. Strong federal protections limiting the duration and availability of
short-term plans are needed to ensure that all consumers are protected.
37
Palanker D, Kona M, Curran E. (2019, May 2). “States step up to protect insurance markets and consumers from
short term health plans.” Commonwealth Fund. Available at
https://www.commonwealthfund.org/publications/issue-briefs/2019/may/states-step-up-protect-markets-
consumers-short-term-plans.
38
Giovannelli J, Lucia K, Corlette S. (2019, Feb). “What is Your State Doing to Affect Access to Adequate Health
Insurance?” The Commonwealth Fund. Available at https://www.commonwealthfund.org/publications/maps-and-
interactives/2019/mar/what-your-state-doing-affect-access-adequate-
health?redirect_source=/publications/maps-and-interactives/2019/feb/what-your-state-doing-affect-access-
adequate-health.
22. 22
Acknowledgements
This work was authored by Anna Schwamlein Howard, Policy Principal, American Cancer Society Cancer
Action Network.
The author gratefully acknowledges the input of Keysha Brooks-Coley, Alissa Crispino, Stephanie
Krenrich, Lisa A. Lacasse, Allison Miller, Cathy Peters, Jennifer Singleterry, Kirsten Sloan, Carter Steger,
Pam Traxel and David Woodmansee at the American Cancer Society Cancer Action Network and Robin
Yabroff at the American Cancer Society.
The author also would like to thank Jean Hearne, Katie Keith, Sarah Lueck, Karen Pollitz for their valuable
insights.
23. 23
Appendix A
For purposes of this report, the author visited a well-known online brokerage website and searched for
short-term, limited-duration health plans using the patient profile of a 57-year-old woman, who
indicated she was a non-smoker. Plan information was sought using the following zip codes:
City State Zip Code Urban/Rural
Chicago IL 60639 Urban
LaSalle IL 61301 Rural
Houston TX 77051 Urban
Mission TX 78572 Rural
Portland ME 04103 Urban
Allagash ME 04774 Rural
Miami-Dade FL 33172 Urban
Jackson FL 32446 Rural
Milwaukee WI 53202 Urban
Waupaca WI 54981 Rural
Pittsburgh PA 15286 Urban
Towanda PA 18848 Rural
Plan information was solicited in November 2018 for five states. Plan information for Pennsylvania was
solicited in March 2019.
Information regarding premiums, deductibles, and plan duration was based on the index provided by
the online broker. In addition, the authors selected specific plans – including the least expensive and
most expensive plans in each of the zip codes examined. The author recorded the online broker’s
summary information regarding the plan. The broker’s summary information also contained direct links
to the issuer’s plan brochure and plan exclusions and exceptions. For all but one issuer included its
plan’s exclusions within the plan brochure. This issuer provided plan exclusion information as a separate
document, accessible via a separate link.
24. 24
Appendix B
In September-December 2016, experts at Avalere Health, LLC, the American Cancer Society and the
American Cancer Society Cancer Action Network (ACS CAN) created three profiles of cancer patients
and treatment regimens. Avalere analysts ran each patient profile through three insurance scenarios
and calculated patient out-of-pocket costs and total healthcare costs. These profiles can be found at
https://www.fightcancer.org/policy-resources/costs-cancer. Following is detailed methodology for
the breast cancer patient profile, Mary.
Mary had Stage I breast cancer. She had one tumor that measured 1 cm in size. Her breast cancer was
hormone-receptive positive and HER2 negative. Her RT-PCR score was 20, which meant that her
cancer might come back, so Mary chose to have adjuvant chemotherapy. Her oncologist also
recommended radiation treatment to stop her cancer from returning. Mary was assumed to be
diagnosed in the first month of coverage of each of the plans examined in this report. Mary’s
treatment regimen was based on National Comprehensive Cancer Network (NCCN) Guidelines for
patients with Mary’s profile. The treatment regimen included:
Mammogram
Ultrasound
CBC and liver function tests
Breast MRI
Core needle biopsy
Lumpectomy (surgery)
Sentinel lymph node biopsy
Hormone receptor and oncotype tests
Chemotherapy – dose-dense AC and paclitaxel
Supportive care drugs – filgrastim, aprepitant, dexamethasone, ondansetron
Monitoring blood tests
EBRT (radiation)
Adjuvant hormone therapy – letrozole
Multiple primary care provider visits
Multiple specialist visits with a medical oncologist, radiation oncologist, breast surgeon
Individual Market Insurance Scenario
The treatment costs used in this model were average commercial costs across private payers taken
from MEPS and HCUP data sets. 2014 was the most recent year available for these data sets at the
time of the analysis of the Cost of Cancer report. In instances where commercial rates were not
available, 100 percent of published 2016 Medicare rates from the following fee schedules were used:
Medicare Physician Fee Schedule, Outpatient Prospective Payment System, Inpatient Prospective
Payment Systems, and Clinical Lab Fee Schedule.
25. 25
The costs used in this model for pharmacological treatments are as follows. For intravenous drugs,
average sales price (ASP) data from the Centers for Medicare and Medicaid Services (CMS) October
2016 pricing file were used, reflecting ASP plus 6 percent. Though some plans may reimburse based
on other methodologies, their methodologies are not always made publicly available, which creates
challenges in estimating precise payment amounts; using the Medicare rate should serve as a
reasonable estimate for most payers. For oral drugs, prices were obtained from the Medicare Plan
Finder, assuming the patient lived in Texas zip code 77025. These data were used to represent
negotiated prices similar to those negotiated by an insurance plan.
It was assumed that all treatment received was in-network and covered – note that patient costs
would likely increase with out-of-network or non-covered treatments.
The Costs of Cancer: Addressing Patient Costs report and accompanying materials can be found at
https://www.fightcancer.org/policy-resources/costs-cancer.